Scoliosis in the adult

INTRODUCTION — Scoliosis in the adult is one aspect of adult spinal deformity (ASD), which also includes kyphosis and spondylolisthesis. These entities can affect the cervical, thoracic and lumbar spine as well as the pelvis.

Scoliosis is an abnormal lateral curvature of the spine that may lead to physical and psychosocial impairments depending on its severity [1,2]. Scoliosis often begins in adolescence or childhood and may not recognized prior to adulthood, or it can develop de novo during adulthood.

The clinical features, evaluation, diagnosis, and management of scoliosis in adults will be reviewed here. Kyphosis as well as spondylolisthesis often occur along with scoliosis in the adult and are discussed separately. (See "Hyperkyphosis in older persons" and "Subacute and chronic low back pain: Surgical treatment".)

Scoliosis in adolescents is discussed separately. (See "Adolescent idiopathic scoliosis: Clinical features, evaluation, and diagnosis" and "Adolescent idiopathic scoliosis: Management and prognosis".)

TERMINOLOGY

●Adult spinal deformity – Adult spinal deformity (ASD) encompasses scoliosis, hyperkyphosis, hypokyphosis, hypolordosis and spondylolisthesis, each of which can lead to imbalance of the structural support of the spinal column [3,4].

●Scoliosis – Adult scoliosis is defined as a lateral curvature of the spine in the coronal plane that is >10 degrees (measured by the Cobb angle (image 1)) in a skeletally mature patient [5]. Curves with Cobb angle ≤10 degrees are considered within normal limits of spinal asymmetry [6].

•The direction (left or right) of the scoliosis is determined by the convexity.

•The location is defined by the vertebral body that is most deviated and rotated from midline (ie, the apical vertebral body) [7]:

-Cervical – C2 to C6

-Cervicothoracic – C7 or T1

-Thoracic – T2 to T11

-Thoracolumbar – T12 or L1

-Lumbar – L2 to L4

-Lumbosacral – L5 or below

●Kyphosis – Kyphosis describes forward curvature of the thoracic spine, or the cervical-thoracic spine in the sagittal plane. The degree of kyphosis is measured by the Cobb angle (figure 1), with a normal thoracic kyphosis generally considered to be between 30 and 50 degrees. Kyphosis is typically not a clinical concern unless it is over 60 to 70 degrees. Regional deformity results when the Cobb angle is <30 degrees (known as hypokyphosis, or "straight back syndrome") or >50 degrees (hyperkyphosis, commonly referred to as "dowager hump") [4,8]. Hypokyphosis is often associated with thoracic scoliosis and can result in decreased cardiopulmonary volume.

●Lumbar hypolordosis – Lordosis refers to the normal posterior curvature of the cervical and lumbar spine in the sagittal plane (figure 2). The degree of lordosis is measured by the Cobb angle. Normal lumbar lordosis is between 35 and 80 degrees [8]. Hypolordosis is defined by lumbar lordosis of <35 degrees. Fixed sagittal imbalance, commonly known as "flatback syndrome," occurs when a hypolordotic spinal deformity prevents a patient from being able to stand up straight [9].

●Spondylolisthesis – Spondylolisthesis is defined as displacement of a vertebral body in relation to the vertebral body below it. The superior vertebral body may be displaced anteriorly (anterolisthesis), laterally lateral (lateral listhesis), or posteriorly (retrolisthesis) (figure 3). The angular deformity of scoliosis often results in a lateral listhesis in the lumbar spine most commonly at L3-4, which can progress and cause back as well as leg symptoms with spinal stenosis [10]. Spondylolisthesis progression can be assessed with careful radiograph assessment, along with Cobb angle measurements for deformity.

ETIOLOGY AND CLASSIFICATION — The most common causes of adult scoliosis are de novo scoliosis (scoliosis associated with degenerative changes in patients with no previous history of scoliosis) and progression of adolescent idiopathic, congenital, or early-onset scoliosis [11]. Genetic factors are thought to play a role in adolescent idiopathic scoliosis. (See "Adolescent idiopathic scoliosis: Clinical features, evaluation, and diagnosis", section on 'Etiology'.)

Less commonly, adult scoliosis is secondary to an underlying medical condition, including neurologic conditions such as stroke and Parkinson disease, posttraumatic paralysis, fracture(s), or spinal surgery. In some cases, an acute lumbar disc herniation can result in the sudden onset of spinal deformity [12]. Postsurgical spinal deformity may result from weakening of the spine after laminectomy or adjacent level failure after spinal instrumentation and fusion.

Adult scoliosis is sometimes classified according to etiology as follows [6,13]:

●Type I – Primary degenerative (or de novo) scoliosis.

●Type II – Progressive adolescent idiopathic scoliosis with secondary degenerative changes.

●Type IIIA – Secondary adult scoliosis due to adjacent thoracic or thoracolumbar curve of idiopathic, neuromuscular, or congenital origin (with or without previous fusion surgery), or leg length discrepancy causing pelvic obliquity. Neuromuscular causes include Parkinson disease, Marfan syndrome, Arnold-Chiari malformation, and syringomyelia (table 1A-B).

●Type IIIB – Secondary deformity progressing due to bone weakness, with osteoporotic fracture(s).

EPIDEMIOLOGY AND PATHOGENESIS — The overall prevalence of adult spinal deformity (ASD) is 32 percent and increases with age, with estimates ranging from 8 percent in adults age 25 to 74 and increasing to 68 percent among adults ≥50 years [14-17]. The prevalence of adult scoliosis varies with the population studied but is inversely proportional to the magnitude of the curve, with many patients having asymptomatic minor degrees of curvature [14,16-21].

The spine is a complex 25-segment structure, which is subject to millions of cycles of movement, high compression and rotational and tensile loading. The bony elements are separated at each level with cartilaginous discs and two facet joints, which allow for some movement and shock absorbency.

Adult degenerative scoliosis usually begins with asymmetric degeneration of the intervertebral disc and facet joints, which leads to unbalanced loading of the spine [13,22-25]. During the growing years, asymmetric disc angulation for any reason can cause asymmetric loading on the disc as well as the epiphyseal plate cartilage, which can slow the chondrocyte production on the concavity, which can result in vertebral body wedging and a scoliosis in the coronal plane, and kyphosis such as Scheuermann’s kyphosis in the sagittal plane. These angled vertebrae and discs cause increased loading on the discs and facet joints then throughout adulthood, which can lead to ongoing curve progression.

Many adult scoliosis patients initially develop their deformity during their pediatric and adolescent growth years and face an increased risk of curve progression during adulthood [10,26]. Curves under 30 degrees tend not to progress during adulthood, whereas curves that are 30-= to 50 degrees have a 70 to 80 percent risk of progression, and curves 50 degrees or more have nearly 100 percent risk of progression [10,26,27]. During childhood and adolescence, scoliosis can progress due to the Hueter-Volkmann Law, where compression of the growth plates on the concavity can lead to slowed bone growth and progressive wedging of the vertebral bodies [28]. During adulthood, asymmetric loading of the discs and the facet joints can also cause ongoing damage and curve progression. Asymmetric disc loading due to angulation of a disc space results in higher loads on the chondrocytes on the concave, narrowed side. This increased load decreases chondrocyte production of proteoglycan and collagen, resulting in tissue weakening, causing further disc space collapse on the concavity with increased angulation and subsequent increased loading again on the concavity, completing the “vicious cycle” [29]. Asymmetric degeneration can also be accelerated by osteopenia or osteoporosis [30,31].

Increasing scoliosis may be associated with sagittal imbalance and spondylolisthesis [4,9]. Progression can be linear, at approximately 0.5 to 1 degree per year, but in some cases can progress much more rapidly, at over 20 to 30 degrees per year as buckling and/or fracture occurs. Weight and/or hormonal changes during pregnancy and menopause may be contributing factors to the potential for more rapid curve progression [32,33].

Concomitant coronal imbalance (lateral trunk shift) and sagittal imbalance (eg, "flatback syndrome," kyphosis) exacerbate abnormal stress and asymmetric load on the discs especially in the lower lumbar region. This can lead to some cases of very rapid curve progression with severe posture changes in the matter of weeks or months, contributing to the cycle of progressive spinal deformity [4].

Tilting of the vertebral bodies can also lead to spondylolisthesis. When the endplate and disc are tilted, a shear force is created which can lead to a shear failure with translation of the upper vertebra “downhill” to the lower vertebra. The resulting spondylolisthesis can progress over time. Anterior spondylolisthesis (anterolisthesis) is often associated with pars fractures (spondylolysis) at L5-S1 especially, which increases the shear stress on the disc, leading to a potential progressive slip. Angular, rotational, and translational failure of the discs and facet joints over multiple spine segments results in a complex three-dimensional deformity, which in some cases can lead to a “buckling” with rapid curve progression.

Spinal stenosis and narrowing of the lateral recesses may result from osteophyte formation at the facet joints, disc herniation(s), and disc height loss combined with hypertrophy and calcification of the ligamentum flavum and joint capsules (figure 4). Spinal deformity can not only cause this stenosis process to be accelerated but can also contribute directly to the stenosis due to the mechanical translation of spondylolisthesis as well as the angular narrowing of the neural foramen. Spinal stenosis and nerve root impingement often are more severe at levels affected by the combination of scoliosis, spondylolisthesis, and degenerative changes, often with the affected nerve root being at the level of the spondylolisthesis and/or the root on the narrowed concave side of the curve. Nerve roots can also be affected by traction on the lumbar plexus with trunk shift. It is also important to note that an acute disc herniation can in some cases cause a reactive spinal deformity as the patient leans away from the pain generator. This deformity can correct spontaneously with time, conservative treatments such as epidural steroid injections, or with surgical removal of the affected disc.

CLINICAL PRESENTATION — Patients with spinal deformity are often asymptomatic, although others may have significant symptoms [2,8,14]. Providers of adult patients should be alert to the possibility of undiagnosed scoliosis in their patients. New-onset degenerative adult scoliosis typically has onset at ≥50 years of age as degenerative changes in the spine progress. Congenital, early-onset, and adolescent idiopathic scoliosis have onsets during the growing years and may progress and become symptomatic during adulthood. Many childhood deformities are missed during the growing years and may first be diagnosed by an adult provider.

Symptomatic patients usually present with [13,22,23,34,35]:

●Back pain (in up to 90 percent of patients) [36]

●Postural imbalance with difficulties standing and walking

●Symptoms of spinal stenosis in approximately 50 to 89 percent of patients [37,38] (see "Lumbar spinal stenosis: Pathophysiology, clinical features, and diagnosis", section on 'Symptoms')

•Neurogenic claudication – Unilateral or bilateral thigh and/or leg pain (often asymmetric), sensory loss, and/or weakness affecting the legs; exacerbated by walking, standing, or certain postures

•Radiculopathy – Pain, numbness, tingling, or weakness that radiates into the legs and/or feet

●Neurologic deficits (eg, weakness, numbness, loss of bowel or bladder control) are rare in adult patients with scoliosis; these patients may have spinal cord compression or cauda equina syndrome and require urgent evaluation (see "Anatomy and localization of spinal cord disorders")

●Psychosocial concerns about posture and appearance, worries about future curve progression and depressive mood (eg, decreased height, change in posture, asymmetry, change in fit of clothing) [1]

As the deformity progresses, patients may develop fixed sagittal imbalance (eg, flatback syndrome) [9,35] (see 'Terminology' above). Although degenerative changes may plateau over time, stenosis can continue to worsen, resulting in increasing radiculopathy and/or neurogenic claudication [5]. (See "Lumbar spinal stenosis: Pathophysiology, clinical features, and diagnosis".)

CLINICAL EVALUATION — The goals of the evaluation are to:

●Examine the spine for clinical findings suggestive of scoliosis

●Determine the etiology (primary degenerative, progression of adolescent idiopathic scoliosis, or secondary to another condition such as fracture[s])

●Identify factors contributing to pain

●Assess for referral indications [23,35]

Key features of the examination are outlined in the table (table 2).

Patient history — Important aspects of the history include (table 3):

●Identify patients at risk – Ask about history of spinal deformity when screening new patients and keep a high index of suspicion for undiagnosed scoliosis. Unexpected decreasing height during adulthood is a good marker of potential progressive deformity.

●Onset, time course, and treatments – The age of initial diagnosis, curve magnitude over time, and prior treatments are helpful to determine risk of progression.

●Change in posture or balance – Patient-reported change in posture, such as an increasing hump on their back or chest wall deformity or trunk balance, may indicate curve progression, fracture-related vertebral body collapse, or buckling of one or more intervertebral discs. Patients will sometimes have older photographs and/or radiographs that can be very helpful to document changes in posture and curve progression. Identifying and collecting all older radiographs with curve magnitudes and encouraging the patient to keep a record over time can be helpful.

●Loss of height – It can be helpful to ask the patient if they remember how tall they were when they obtained their driver's license or when they graduated from high school and compare that with current height.

●Presence, time course, and characterization of pain – Not all spinal deformity patients have pain, but many do develop pain. Pain related to spinal deformity should be assessed by:

•Location – Have the patient point to specific areas that are painful to determine the exact location.

-Focal axial pain in the cervical, thoracic, or lumbar spine may indicate the anatomic site of vertebral fracture

-Pain over a larger area of the thoracic lumbar can be related to degenerative changes, instability, and/or muscle fatigue and spasm [13,35]

-Pain in the buttock and posterior thigh can be referred pain from the lumbar region and/or sacroiliac joint(s)

-Radiation to the legs or radiculopathy suggests spinal stenosis

•Severity – Noting the severity of the pain on a 0 to 10 scale, and the change in severity over time, is critical. Severe and/or worsening pain may require more urgent referral. The severity of pain does not correlate well with the severity of imaging findings or potentially serious causes of pain such as neoplasm, fracture, infection, or other serious pathology that require additional evaluation. (See "Evaluation of low back pain in adults", section on 'Serious etiologies'.)

•Aggravating/relieving factors – Pain caused by scoliosis is aggravated with changes in position, standing, sitting, walking, and/or exertion and is often relieved by lying supine or bracing (which eliminates or decreases the effect of gravity) [16,35].

●Associated symptoms

•Neurologic "red flag" signs – Progressive weakness, clumsiness, numbness, or loss of bowel or bladder control, with or without numbness or shooting extremity pain, suggest a neurologic cause and may require urgent evaluation and possible decompressive surgery for cauda equina syndrome or myelopathy. (See "Anatomy and localization of spinal cord disorders", section on 'Cauda equina syndrome'.)

•Isolated numbness or shooting pain in the legs – Suggests lumbosacral radiculopathy. (See "Acute lumbosacral radiculopathy: Etiology, clinical features, and diagnosis".)

•Shortness of breath – Rarely, restricted cardiopulmonary function is the presenting symptom of thoracic scoliosis [3]. Severe thoracic scoliosis (>60 degrees) and hypokyphosis may decrease cardiorespiratory function by diminishing the size of the chest cavity and restricting normal rib movement, or from restricted movement of the diaphragm due to upward pressure of intra-abdominal contents from thoracolumbar scoliosis curve buckling [39-42].

●Past medical history

•Previous spine surgeries

-Previous laminectomy, especially multilevel laminectomy or laminectomy revision surgery, increases the risk of spinal deformity.

-Previous spinal fusion, especially fused with a large residual deformity, increases the risk of spinal stenosis, spondylolisthesis, and scoliosis above or below to the fusion levels.

-Patients with previous spinal fusions may develop kyphosis above or below a previous fusion, which is called proximal junctional kyphosis and distal junctional kyphosis. Rarely, severe adjacent level failure secondary to fractures or disc and ligament failure can occur, usually within the first few weeks of fusion surgery, which is called proximal junctional failure or distal junctional failure [43]. Adjacent level failure can be is associated with neurologic findings (eg, clumsiness, weakness) and requires urgent referral and likely surgery to prevent permanent neurologic deficits.

•History of hip or knee replacement, infection, or arthritis; hip dysplasia; or lower extremity fracture, amputation, or pediatric leg length discrepancy – May be associated with leg length discrepancy, which can contribute to spinal deformity.

•Osteoporosis or degenerative disc disease – Increases the risk for curve progression and fracture. Obtaining and tracking bone density scores over time is extremely helpful, along with proper prevention and treatment. Severe osteoporosis may delay and/or prevent the ability to perform spinal deformity surgery.

•Menopause – Menopause is associated with progression of scoliosis through disc and ligament accelerated breakdown and spine buckling and/or osteoporotic compression fractures because of the loss of bone density associated with hormonal changes. (See "Clinical manifestations and diagnosis of menopause", section on 'Long-term consequences of estrogen deficiency'.)

•History of associated neurologic conditions – Certain neurologic conditions are commonly associated with scoliosis (eg, Parkinson disease [44], Chiari II [Arnold-Chiari] malformation, cerebral palsy, Charcot-Marie-Tooth syndrome, syringomyelia, spinal cord injury, polio). (See 'Etiology and classification' above.)

•History of genetic conditions affecting collagen and bone – Genetic conditions that affect collagen and bone (eg, Marfan syndrome, Ehlers-Danlos syndrome) are commonly associated with scoliosis. (See 'Etiology and classification' above.)

●Family history of scoliosis – Idiopathic scoliosis has a genetic component. Encouraging adult patients with a history of adolescent idiopathic scoliosis or other pediatric scoliosis to have their children carefully screened may help allow for early successful conservative treatment.

Spine examination

●Inspection – The first step is inspection of the standing patient from behind and from the side. (figure 5) Findings that suggest scoliosis include:

•Lateral curvature of the spine with thoracic (picture 1A-B) or lumbar asymmetry; the most common scoliosis curve is a right thoracic, left lumbar double curve, but many other curve configurations occur [6,45] (see 'Terminology' above)

•Head not centered over the sacrum and/or torso not centered over the pelvis in the coronal plane (ie, trunk shift, or coronal imbalance)

•Asymmetry in shoulder or scapulae height, waistline, or distance that the arms hang from the trunk

Other relevant findings include:

•Increased thoracic kyphosis when viewed from the side

-May be seen with osteoporosis or compression fractures and degenerative disc disease

-May be associated with underlying deformity (eg, Scheuermann kyphosis)

•Decreased thoracic kyphosis (hypokyphosis) when viewed from the side

-May be seen with scoliosis and/or previous back surgery

•Decreased lumbar lordosis when viewed from the side ("flatback syndrome")

-Associated with progression of degenerative scoliosis

●Adam's forward bend test – The Adam's forward bend test evaluates the rotational component of scoliosis by observing the patient from the back while they bend forward at the waist until the spine is parallel to the floor with feet together, knees straight ahead, and arms hanging freely. Thoracic (rib) or lumbar (loin) prominence on one side is a sign of scoliosis (figure 5) [6,46]. This rib prominence can be measured with a scoliometer. Observing the patient from the side may also identify kyphosis and loss of lumbar lordosis.

For patients unable to perform the standing test, patients with leg length discrepancy, or patients with asymmetric hamstring tightness, Adam's forward bend test can be performed with the patient sitting on a chair. An alternative for patients with leg length discrepancy is to place an appropriate-sized block under the short leg [47].

Inability to bend forward at the waist or decreased range of motion with forward or side bending may be secondary to pain, lumbar muscle spasm, and/or tightness of the hamstrings [3,6,8]. Any of these findings may indicate an underlying cause of scoliosis. Acute lumbar disc herniation can cause significant scoliotic postural changes with trunk shift as the patient leans away from the side of the disc herniation.

●Scoliometer – A scoliometer is used to evaluate asymmetry in the upper thoracic, mid-thoracic, thoracolumbar, or lumbar region, by measuring the angle of trunk rotation (ATR). Free or inexpensive scoliometer and bubble level apps are available on mobile devices. Validation studies of scoliometer apps suggested good correlation with traditional scoliometers (picture 2) [48] and bubble level apps. ATR measurements can be documented for the maximum angle within the thoracic, thoracolumbar, and lumbar regions.

As a general guideline, a scoliometer angle of 5 and 7 degrees correspond to a Cobb angle of 11 and 20 degrees [49]. As a result, an ATR of 5 to 7 degrees or greater can be used as an indication to refer to a scoliosis center and/or obtain a full-length scoliosis radiograph. The 5 degree cutoff is also recommended for patients with high body mass index (BMI), since the ATR is much less accurate with increased soft tissue [50]. A provider may also choose to use the 5 degree cutoff with the hope of diagnosing smaller curves that may be amenable to conservative management such as physiotherapeutic scoliosis-specific exercises and to also provide additional longitudinal data for documentation of curve progression, especially for younger adult and growing patients [51].

Potential sources of error in scoliometer measurements include obesity, ambiguous markings for degree increments, inconsistent identification of the curve apex, and inconsistent performance of the Adam's forward bend test [52].

●Palpation – Palpate for areas of tenderness along the spine and pelvis and assess if pain is made better or worse with flexion or extension.

•Localized tenderness of the spine may indicate facet arthritis or fracture

•Localized tenderness of the sacroiliac joints may indicate sacroiliac joint arthritis

•Localized tenderness of pelvis may indicate or a sacral insufficiency fracture in older patients with osteoporosis

General examination — Aspects of the general examination that are helpful in assessing severity and progression in patients with scoliosis include (table 2):

●Height measurement – It is important to measure the patient's height every year and to review the trend over time. For patients ≥40 years, loss of height ≥0.5 inches (1.3 cm) per decade may indicate osteoporotic compression fracture or buckling progression of deformity [53].

●Standing posture, trunk balance – The patient's posture should be assessed in the standing position, checking to see if the head and torso are centered over the pelvis in the coronal and sagittal planes.

•In patients with scoliosis, the head and torso lean to one side in the coronal plane.

•In patients with sagittal imbalance, the head and torso are "pitched forward" in the sagittal plane. There may be associated pelvic retroversion and loss of lordosis, which is identified by flattening of the buttocks [8,22,54-56]. Patients with flexible sagittal imbalance can stand up straight with compensatory flexion of the hips and knees [35]. Patients with fixed sagittal imbalance are no longer able to stand up straight.

●Gait – Gait should be evaluated, including asking the patient to walk on their heels and toes [4]:

•Clumsiness or spasticity or a wide-based gait may indicate cervical or thoracic myelopathy or neuromuscular disease

•Antalgic gait may indicate nerve root compression or pain with weightbearing

•Imbalance may indicate global (coronal and sagittal) imbalance or lower extremity arthritis

•Need for walker or cane indicates unsteadiness

●Strength, sensation, and reflexes in the upper and lower extremities – Abnormalities may indicate myelopathy, radiculopathy, or other neurologic process. For example (see "The detailed neurologic examination in adults"):

•Hyperreflexia, pathologic reflexes, and clonus may indicate myelopathy [4].

•Absent or diminished reflexes may indicate radiculopathy.

●Leg length discrepancy – Leg length discrepancy is assessed by measuring from the anterior superior iliac spine to the caudal edge of medial malleolus bilaterally with the patient in the supine position. Most patients with scoliosis have equal leg lengths but apparent leg length discrepancy because the pelvis tilts to compensate for the lumbar portion of the curve.

Leg length discrepancy may contribute to the pathogenesis of scoliosis through asymmetric loading.

●Signs of congenital genetic condition – Some genetic conditions are associated with spinal deformity, including:

•Marfan syndrome (see "Genetics, clinical features, and diagnosis of Marfan syndrome and related disorders")

•Ehlers-Danlos syndrome (see "Clinical manifestations and diagnosis of Ehlers-Danlos syndromes")

•Neurofibromatosis type 1 (table 4) (see "Neurofibromatosis type 1 (NF1): Pathogenesis, clinical features, and diagnosis")

•Spinal dysraphism (see "Myelomeningocele (spina bifida): Anatomy, clinical manifestations, and complications" and "Closed spinal dysraphism: Clinical manifestations, diagnosis, and management", section on 'Musculoskeletal')

Patients with clinical features of these conditions may have scoliosis secondary to the underlying condition. (See 'Etiology and classification' above.)

Quality of life — The patient's quality of life affects management decisions. Worsening quality of life may require additional or more invasive interventions. (See 'Management' below.)

The patient's quality of life can be assessed informally by asking about:

●Pain with various activities

●Whether and for how long the patient is able to stand and walk

●Whether the patient is able to perform activities of daily living (eg, get in and out of bed)

●Self-image/self-consciousness about posture and appearance (eg, leaning to one side, new skin folds under the rib cage)

Validated tools are available to quantitatively assess quality of life and can be used to monitor quality of life over time. These include the Oswestry Disability Index (figure 6) [57] and Scoliosis Research Society-22 (available in several languages from the Scoliosis Research Society).

RADIOGRAPHIC EVALUATION — The initial radiographic evaluation for scoliosis (standing posteroanterior [PA] and lateral views of the spine on a 36-inch digital cassette) may be ordered by the primary care clinician; however, it may be preferable to have these performed at a scoliosis center/clinic where proper views will be ensured, higher-resolution and lower-radiation slot-scanning radiographic imaging equipment is likely available, and accurate serial Cobb angles can be obtained and compared with less error [58].

Additional views and/or advanced imaging for patients with symptoms or more severe or progressive scoliosis is usually obtained by the spine specialist as indicated to identify correctable causes of scoliosis, evaluate conditions that should be treated before surgical correction of scoliosis, and to plan surgery.

Radiographs — Radiographs are required to confirm the diagnosis of scoliosis, evaluate the etiology (eg, postsurgical, posttraumatic, congenital (image 2A-B), degenerative (image 3)), determine the curve pattern (picture 1B), measure the magnitude of the curve (Cobb angle), evaluate the extent of degenerative changes (to determine the risk for progression), and assess sagittal balance [22,59].

●Indications – Indications for radiographic evaluation in an adult scoliosis patient include:

•Clinically evident spinal deformity on physical examination.

•Scoliometer reading (angle of trunk rotation) 5 degrees or more of angle of trunk rotation (ATR) [51,60,61]. Note that it is more difficult to assess ATR in patients with overweight or obesity, where 1 to 2 degrees or more of error can be expected [50].

•Curve progression monitoring of patients previously diagnosed with scoliosis.

●Views – The initial radiographic evaluation of scoliosis includes standing posteroanterior (PA) and lateral views of the spine on a 36-inch digital cassette that can portray the entire spine.

PA views minimize radiation exposure to the thyroid and breasts. The lateral view assesses spinal deformities in the sagittal plane (eg, kyphosis, loss of lumbar lordosis) and pelvic parameters. In scoliosis patients, lumbar lordosis and thoracic kyphosis are often reduced. Increased thoracic kyphosis may suggest underlying pathology, particularly osteoporosis [4]. Lateral views can also show abnormalities such as spondylolysis and spondylolisthesis. If there is no significant deformity in the sagittal plane, follow-up radiographs can be obtained in the PA plane only to cut down on radiation exposure.

To accurately measure spinal balance and curvature on PA and lateral radiographs, the patient should be standing with their knees extended, hips relaxed, and fingertips placed on the clavicles [8,62]. Standing radiographs are required because lying down eliminates the effect of gravity, reduces the magnitude of the curve, and limits the ability to assess coronal and sagittal balance [62-65]. Leg-length discrepancy can be corrected before imaging by using the patient's existing shoe lift or an appropriately sized block or having the patient in a seated position; the radiograph should be labeled to indicate the side and size of the shoe lift or block.

The radiographs should capture the complete spine from the occipital condyles to the femoral heads [8,62,66]. This can be accomplished with either a full-length, 36-inch digital cassette or with low-dose, three-dimensional spine imaging (stereoradiography) [58]. Although it is not widely available, low-dose, three-dimensional spine imaging can provide better understanding of the deformity and include the lower extremities to evaluate the effect of leg lengths and joint contractures [67-69]. If neither a 36-inch cassette nor low-dose, three-dimensional stereoradiography is available, separate thoracic and lumbar radiographs can be obtained, but measurement of curves and global balance will be more difficult, potentially less accurate, and likely require manual “stitching.”

●Radiographic findings of scoliosis – The diagnosis of scoliosis is confirmed by a Cobb angle of >10 degrees of lateral curvature (image 1). Usually there are three Cobb angles that are measurable, which include one or two structural curves and one or two compensatory curves.

The Cobb angle is the standard for quantifying the magnitude of a curve in scoliosis [70]. The Cobb angle is formed by intersecting a line parallel to the superior end plate of the most tilted cephalad vertebra in a specific curve, with the line parallel to the inferior end plate of the most tilted caudad vertebra of the curve (image 1).

Although the Cobb angle is the accepted standard for measuring scoliosis on radiographs, it has limitations. It does not measure rotational deformity and is not directly proportionate to the severity of scoliosis [49,71]. Variation in measurement error is between 1 and 5 degrees [62,72-74].

Clinicians treating spinal deformity patients must have training and experience in measuring Cobb angles and should have a digital system that includes measurement functions or, at the very least, the capacity for a good-quality paper printout of the digital image to manually measure the Cobb angle [75]. If possible, it is important to use the same method of measurement when comparing Cobb angles over time, preferably by the same observer.

The severity of scoliosis increases with increasing Cobb angle. The severity of trunk shift can be assessed by measuring the distance that the rib cage "overhangs" the lateral border of the iliac crest. The severity of lateral listhesis (often associated with lumbar scoliosis, most commonly at L3-L4) can be measured in millimeters of vertebral body overhang and is associated with curve progression [26]. The severity of rotation can be assessed by examining the degree of asymmetry of the appearance of the pedicles at each level, which has been an important prognostic indicator for curve progression [26].

●Radiographic measurement of sagittal imbalance – The sagittal vertical axis (SVA) is a measure of sagittal balance. It is the horizontal distance from the C7 plumb line to the posterior superior corner of the end plate of the S1 vertebra (figure 7). SVA ≥4 cm has been associated with increasing pain and disability [70,76].

●Other spinopelvic parameters – A discussion of other radiographic spinopelvic parameters (eg, pelvic incidence, pelvic tilt) is beyond the scope of this review but available from the Scoliosis Research Society.

MRI of the spine — Magnetic resonance imaging (MRI) of the spine is indicated in patients with spinal deformity and clinical or radiographic findings suggestive of intraspinal pathology or patients who are experiencing neurologic symptoms. MRI may be superior to computed tomography (CT) of the spine for evaluating intervertebral disc herniations and spinal stenosis of the central canal, lateral recess, and/or neural foramen and is also helpful looking for evidence of neoplasm and infection, as well as some fractures not picked up on radiograph. (See "Evaluation of low back pain in adults", section on 'Limited utility of imaging'.)

Relevant MRI findings may include:

●Lumbar spinal stenosis and conditions that cause or aggravate lumbar spinal stenosis (eg, lateral, anterior, or posterior spondylolisthesis, facet osteophytes or cysts, severe ligamentum flavum hypertrophy, spinal fractures or fracture fragments)

●Spinal cord compression and spinal cord signal change (may be difficult to interpret if the spinal deformity is severe)

MRI is more sensitive and specific than myelography in the evaluation of intraspinal anomalies and avoids ionizing radiation and the risk of spinal fluid leak and possible dye reaction [77].

CT of the spine — CT of the spine is useful in evaluating the bony anatomy (eg, fractures such as spondylolysis, severity of disc degeneration and disc instability, and osteophytes in the spinal foramen) and the integrity of spinal fusion and hardware from previous surgery (eg, loose pedicle screws) [62]. CT scans also can provide a more accurate measurement of axial rotation than radiographs but may underestimate actual rotation when standing. CT scans can also be used to measure vertebral body bone density directly via the Trabecular Bone Score or Hounsfield units but require significantly more ionizing radiation than dual-energy X-ray absorptiometry (DEXA) scans [62,78,79]. Hounsfield scores are typically performed on the L2 vertebra, with osteoporosis typically defined as under 85 Hounsfield units, which may indicate need for more aggressive osteoporosis treatment especially if spinal instrumentation surgery may be necessary in the future.

Potential indications for CT include:

●Assessment of spinal stenosis and other pathologies in patients who are not candidates for MRI (eg, cochlear implant, certain pacemakers, and spinal cord stimulators)

●Improved assessment of bony anatomy in patients with congenital scoliosis or vertebral fractures

●Assessment of the position and possible loosening of spinal implants, and possible pseudarthrosis

DIAGNOSIS — Adult scoliosis is a radiologic diagnosis. Criteria for the diagnosis include:

●Lateral (coronal) curvature with Cobb angle of >10 degrees

●Complete closure of the iliac crest epiphysis (Risser 5 (figure 8))

The severity of scoliosis increases with increasing Cobb angle. The curve pattern and associated sagittal deformity can be categorized according to a variety of systems that are used in making decisions about surgery (eg, King-Moe, Lenke, Schwab, Scoliosis Research Society-Schwab) [7,76,80-84]. Discussion of these classification systems is beyond the scope of this review but is available from the Scoliosis Research Society.

CURVE PROGRESSION — The majority of adult scoliosis patients will have curve progression; however, the pace and the clinical consequences of progression are uncertain. For many patients with mild scoliosis, the progression may not be enough to lead to symptoms or clinical consequences. Curves may be stable for many years and then progress rapidly [10,26,85]. Given the biomechanical complexity of the human spine, combined with variability in cartilage, bone biology, ligament and muscle biology, an 80-plus year lifespan with millions and millions of cycles of loading, combined with social and psychological variability, there is always significant uncertainty in the potential long-term outcome of any human with a spinal deformity [86].

As a result of this lifelong “cone of uncertainty” for the individual patient, long-term curve tracking with radiographic Cobb angle measures, education, and management is recommended. At the same time, old-school “rules of thumb” such as “curves under 40 or 45 degrees will not progress during adulthood” should not be used and should be corrected to prevent false reassurance. Respecting patient preferences and values, patients with scoliosis should be offered the choice of lifelong follow-up of their curves especially as they transition from pediatric to adult care. This is especially important for curves that are 30 degrees or more, which are more likely to progress [26].

There are a few long-term outcome studies that have examined scoliosis curve progression [10,26,85,87]:

●In a 40-year longitudinal study of 102 patients from Iowa who had adolescent idiopathic scoliosis as a young adult, the overall progression rate was 68 percent, with curves under 30 degrees very unlikely to progress, and nearly 100 percent of curves over 50 degrees progressing [10,26]. In between these two zones, curves that were 30 to 50 degrees had approximately 70 to 80 percent risk of progression. A patient/family educational handout based on this study has been created and can be used for shared decision-making in pediatric and adult patients [88].

●De novo adult-onset scoliosis patients have also been studied. In a longitudinal study of 200 patients ≥50 years of age with degenerative lumbar scoliosis, curves progressed at an average of 3 degrees per year (range 1 to 6 degrees) [89]. In another longitudinal study, 11 of 42 female patients with degenerative lumbar scoliosis progressed ≥5 degrees during a mean follow-up of 12 years [90].

Factors that appear to increase the risk for progression include:

●Cobb angle >30 degrees or curves 20 to 30 degrees with severe rotation [89,91,92].

●Lumbar curve – Lumbar curves progress more rapidly and to a greater extent than thoracic curves [4,89]. Additional risk factors specific to lumbar curve progression include Cobb angle >30 degrees, lateral listhesis >6 mm, and fixed angulation in the coronal plane of L5 on S1 [22,93].

●History of decompression laminectomy without spinal fusion [94].

●Osteoporosis, especially with known vertebral fracture.

Progression of curves in patients with a history of adolescent idiopathic scoliosis is discussed separately. (See "Adolescent idiopathic scoliosis: Management and prognosis", section on 'Outcome'.)

MANAGEMENT — Management of spinal deformity in adults consists of providing continuity of care, monitoring progression, and symptomatic patient treatment. Treatments are always individualized according to etiology, severity of symptoms, and quality of life. Pain and functional limitations (eg, increased back and leg pain with walking) play a major role in the decision to undergo surgery for adult scoliosis [95,96]. Overall management can be thought of in three stages: conservative (level 1), injections (level 2), and, when appropriate, surgery (level 3).

Primary care management

Ensuring continuity of care — Adult patients with spinal deformity can benefit from primary care management regardless of whether they are symptomatic. Such providers can help provide a “bridge” for patients who were diagnosed with deformity as a child or adolescent to provide education on prevention and follow-up choices and possible referral. One common complaint from adult patients with symptomatic scoliosis later in life is that they were told by their provider as an adolescent or younger adult that their deformity would not progress and that no further follow-up was needed, but a decade or more later they discovered that this was not the case [97].

Key features of ongoing care include:

●Osteoporosis prevention and treatment – Ensuring adequate calcium and vitamin D and calcium intake, including supplementation as needed, is especially important for patients with spinal deformity. Spinal deformity not only puts more loads on the discs leading to the “vicious cycle” of disc collapse in some cases, but then also puts the patient at risk for osteoporotic fractures in life, which can cause suffering and rapid progression of the deformity. Screening, prevention, and treatment of osteoporosis are discussed elsewhere. (See "Screening for osteoporosis in postmenopausal women and men" and "Overview of the management of low bone mass and osteoporosis in postmenopausal women" and "Treatment of osteoporosis in men".)

●Monitoring of curve progression – Educating patients regarding the risk of spinal deformity progression is an important part of care during adulthood. We encourage patients to gather and keep all of their previous imaging, as well as copies of the spinal deformity treatment notes.

Some patients may be under the false impression that there is a safe Cobb angle below which a guarantee can be made that the curve will not progress. Curves under 30 degrees have less than a 5 percent risk of progression, curves 30 to 50 degrees have a 70 to 80 percent risk, and curves 50 degrees and above have almost 100 percent risk of progression [10,26]. Kyphosis can also progress as an adult, especially with Cobb angles over 60 degrees.

Primary care providers should measure and document height, angle of trunk rotation (ATR), and signs of shoulder obliquity and trunk shift annually or refer the patient to a spine specialist who can follow these parameters.

●Encourage proper exercise, diet, and weight management – Underweight patients should be encouraged to gain and maintain proper weight, while overweight patients should be encouraged to lose weight to decrease the load on their spine. There is a 5:1 ratio for the load on the spine, with 1 pound weight loss decreasing load on the spine by 5 pounds. Even small amounts of weight loss can significantly decrease the loads on the spine and may help prevent or improve back and leg symptoms and potentially even help decrease the risk of curve progression and spinal stenosis [98].

●Shared decision-making – Early detection of adult progression is important due to the availability of noninvasive treatments, which may halt or even partially correct progression. Such treatments include physiotherapeutic scoliosis-specific exercises, including Schroth therapy [99]. Shared decision-making can also be undertaken as an adult to allow the patient to consider the risks/benefits of earlier surgical intervention for patients at significant risk of lifetime curve progression, since earlier surgery can in some cases allow for a shorter fusion, less risk of complications, and faster recovery, often at a time in life where there is less impact on work and school and also more social support and health insurance is available [87].

Symptomatic patient management — The primary care provider can also help with management of the symptomatic spinal deformity patient. Back or leg pain, weakness, numbness, perceived changes in posture, and/or difficulties with activities of daily living are indications for treatment.

Initial treatment with conservative measures is appropriate for patients without "red flag" findings (progressive weakness, clumsiness, numbness, radiating extremity pain, or loss of bowel and bladder control) or progressive neurologic deficits, with stable coronal and sagittal balance, and with stable curves (progression of ≤1 degree per year) [22,100-103]. Patients with "red flag" signs should have urgent surgical referral.

The patient and treating clinician must have realistic expectations regarding the benefits and costs of conservative therapy [35,104]. The goal of conservative management is to decrease pain and maintain or improve function, quality of life, and stamina rather than correct the spinal deformity. Randomized trials of conservative treatments for adult scoliosis are few but do show some benefit for treatment [105]. In observational studies, conservative interventions have been associated with improved pain, posture, balance, and/or self-image in some patients [106-109].

The first round of conservative treatment for scoliosis is similar to conservative treatment for other types of back pain, which is discussed separately. (See "Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment".)

Here is a simple level 1 treatment plan for the patient with symptomatic adult deformity:

●Lightweight pull-string corset-like lumbar brace. This brace can be purchased over the counter or for less than USD $50 in the United States. For more severe curves, or in cases where the “pulley” lumbar brace is not adequate, an orthotist can help by providing a thoracolumbar prefabricated brace or, in some cases, a custom brace such as the Rigo-Cheneau Brace (picture 3).

●Turmeric 1500 mg daily, which may help decrease inflammation and pain [110].

●Long-acting nonsteroidal antiinflammatory drugs (NSAIDs) such as naproxen, if not contraindicated, and/or acetaminophen, 1000 mg up to three times daily [111].

●Thirty minutes of low-impact aerobic exercise daily. For patients with difficulty standing or walking, a recumbent bicycle is a good alternative.

●If overweight, a weight loss diet; if underweight, encourage weight gain.

In addition to more general conservative therapies, the following interventions are specific to scoliosis:

●Physical therapy and home exercise program – A physiotherapeutic scoliosis-specific exercises (PSSE) program, such as the Schroth technique, is the first choice if available. If Schroth-certified training is not available, there are a series of simple spinal deformity exercises that can be taught to the patient that include seated wall reach, prone on feet, semi-hanging or long-hanging, planks, and maintaining a “corrected posture” when sitting and standing. A local physical therapist could possibly help teach these exercises to the patient and family. These may provide reduction of curvature [112] and improve quality of life and appearance [113,114].

●Modified Pilates exercise programs may improve strength and quality of life [115].

●Shoe lifts for patients with actual or apparent leg length discrepancy contributing to scoliosis to help correct coronal balance and help with back pain. Apparent leg length discrepancies occur when the leg lengths are actually equal but the patient has pelvic obliquity caused by the spinal deformity.

●Soft bracing can be used to provide spinal support (which may improve ambulatory function) and short-term pain relief, but a soft brace will not stop the curve from progressing in an adult scoliosis patient [116].

●Firm orthoses, including custom-molded plastic braces such as the Rigo-Cheneau brace (picture 3), may help slow the rate of progression of the scoliosis and improve back pain, especially when combined with physiotherapeutic scoliosis-specific exercises including Schroth therapy (picture 3).

●For older patients with more severe deformity, a four-wheel rolling “rollator” walker with brakes and seat allows the patient to walk with better posture and balance. It can improve mobility, decrease pain, and reduce the risk of falls [117].

Indications for referral — Indications for referral to a scoliosis spine specialist in patients with scoliosis include:

●Patients with known spinal deformity who would like to have their scoliosis curve monitored annually to collect curve progression data over time to allow for earlier conservative and/or surgical treatment options to be considered.

●Unexpected height loss and/or posture change suggesting curve progression and/or documented curve progression >4 degrees during adulthood.

●Progressive weakness, clumsiness, numbness, or loss of bowel or bladder control. These "red flag" signs may indicate acute spinal cord compression or cauda equina syndrome and require urgent referral.

●Persistent pain affecting quality of life despite conservative measures such as analgesia, bracing, weight loss, and/or physical therapy (see 'Primary care management' above)

●Radicular pain, such as neurogenic claudication or sciatica. This may be effectively treated conservatively with injections, even in patients with spinal deformity [101].

●Shortness of breath that is thought to be due to spinal deformity.

Local scoliosis providers can be found through the Scoliosis Research Society.

Specialist management — Specialist management of the adult patient with scoliosis includes serial monitoring of symptoms, quality of life, and curve magnitude as well as shared decision-making regarding additional interventions, including physical therapy, bracing, spinal injections, and surgery.

Serial monitoring — Longitudinal radiographic data can be helpful in assessing curve progression over time, and patients should be encouraged to keep copies of their radiographs and measurements. The frequency and type of follow-up for patients with adult scoliosis is individualized according to the type of scoliosis (primary degenerative scoliosis, progressive adolescent idiopathic scoliosis, secondary scoliosis), magnitude (as indicated by the Cobb angle), previous interventions, progression, and preference of the treating surgeon, but it is often once a year.

Serial monitoring of clinical features and radiographs allows the patient and provider to understand the rate of progression. This permits shared decision-making regarding the possibility of earlier, less invasive surgical treatment when appropriate (see 'Surgical intervention' below). Use of curve progression versus age graph handouts helps adult patients understand the potential lifelong effects of their deformity.

The patient's quality of life should also be monitored over time, including pain level, standing and walking time/distance and abilities to perform activities of daily living (see 'Quality of life' above). The quality of life in adult scoliosis patients may remain stable for decades. However, in some patients, it may decline gradually, then decrease dramatically over weeks to months, with markedly increased pain, disability, and deformity. This can occur through spine buckling, sometimes combined with osteoporotic fractures. For patients who decline despite conservative treatment, earlier specialist referral may prevent patient suffering, decrease use of analgesic medications, and decrease deconditioning.

Injection therapies — There is some evidence to support the use of epidural glucocorticoid injections for radicular pain in patients with scoliosis [101]. Epidural glucocorticoid injection may be reasonable for scoliosis patients with lumbar stenosis with neurogenic claudication or lumbosacral radiculopathy who have not improved with conservative treatment. However, given that most of these patients have degenerative arthritis and spinal stenosis, benefits are limited and short term. Although the risk of adverse effects is not increased in adult scoliosis patients, the epidural injection may be more challenging than in patients without scoliosis. Epidural glucocorticoid injections should be limited to three per year to prevent damage to the dural nerve sac, which could lead to a dural leak. Therefore, a successful epidural should last at least four months. (See "Subacute and chronic low back pain: Nonsurgical interventional treatment", section on 'Epidural injection' and "Lumbar spinal stenosis: Treatment and prognosis", section on 'Epidural injections'.)

Radiofrequency ablation (RFA) of selected lumbar facet joints has been shown to be effective for some patients with low back pain, but its effectiveness in adult scoliosis is not specifically known [118]. Glucocorticoid injections with or without a local anesthetic into the facet joints have not been shown to be effective in the treatment of low back pain, but they may be helpful in identifying the source of pain for surgical planning [23,35,119]. (See "Subacute and chronic low back pain: Nonsurgical interventional treatment", section on 'Facet joint injection and medial branch block'.)

Surgical intervention — Surgical intervention for spinal deformity can be performed for both the prevention of the potential long-term effects of the disorder as well as treatment of those effects later in life when and if they occur. The goals of spinal deformity surgery for scoliosis and/or kyphosis are to improve and/or maintain quality of life (pain, walking, working, activities of daily living), improve posture and self-image, and/or to improve and stop the progression of spinal deformity and potential negative impacts later in life [4,120-122]. A shared decision-making approach is recommended [123,124].

The following should be present prior to considering spinal deformity surgery:

●A potential benefit of surgery meaningful to the patient, either now or in the future, such as maintaining quality of life and/or preventing curve progression and allowing the deformity to be treated with a smaller surgery with less risk of complications and faster recovery.

●Unacceptable and/or worsening quality of life (posture/self-image and psychosocial personal factors, pain, work, activities of daily living), documented adult curve progression, or patient-perceived unacceptable risk of future curve progression and quality of life issues in the future that can be addressed with less risk, less personal cost, and better correction at a younger age [87].

●Lack of adequate response to conservative therapies such as treatments and injection treatments for pain and/or neurologic deficits (if appropriate).

●Surgically correctable problem(s) such as spinal stenosis and/or spinal deformity/collapse.

●Medical ability to undergo the procedure, including adequate bone density.

●Full understanding of the risks and benefits of the procedure, tailored to the patient’s specific situation (a detailed shared decision-making checklist can be very helpful for this process).

The surgical procedure is individualized according to clinical and radiographic findings (eg, source of pain, functional impairment, comorbidities, past surgical history, severity of coronal and sagittal deformity, curve progression) [22].

For patients with isolated radicular and/or neurogenic claudication symptoms, surgical decompression with a laminectomy or foraminotomy may decompress the symptomatic nerve root(s) while possibly preserving spinal stability. Spinal deformity caused by lumbar disc herniation can also be treated with a decompression-only approach. In cases with milder deformity, less invasive short segment instrumentation and fusions can be considered with or without decompression. Decompression-only procedures, however, can destabilize the spine and lead to progression of the deformity. As a result, careful preoperative stability assessments with radiographic and CT scan imaging, as well as possible postoperative serial radiographic examination after decompressive surgery in patients with spinal deformity, may help curve progression in this population.

Outcomes — In observational studies, surgical interventions have been associated with improved quality of life, decreased pain, and improved self-image in scoliosis patients [109,125-127]. However, the potential benefits must be balanced against the risk of surgical complications, including reoperation for instrumentation or graft failure.

There has been at least one randomized control trial performed to compare the outcome of conservative verses surgical treatment for adult symptomatic lumbar scoliosis [128,129]. In this trial, 63 patients with symptomatic lumbar scoliosis were randomized to either operative or nonoperative care, with an additional observation cohort of 223 patients. At two years, patients in the randomized groups had similar outcomes in an intention-to-treat analysis. However, as there was a 64 percent nonoperative-to-operative crossover, an as-treated analysis was also performed in which operative treatment patients had greater improvement in self-reported quality of life and disability scores. Operative treatment was associated with better outcomes in the observational cohort as well, except for patients with near-normal lordosis [130].

Complications — In a retrospective review of the Scoliosis Research Society database of 4990 patients undergoing surgery for adult degenerative or idiopathic scoliosis between 2004 and 2007, the overall complication rate was 13.4 percent [131]. Dural tear was the most common complication (2.9 percent), followed by implant complication (1.6 percent), deep wound infection (1.5 percent), acute neurological deficits (1.0 percent), superficial wound infection (0.9 percent), delayed neurological deficits (0.5 percent), wound hematoma (0.4 percent), death (0.3 percent), epidural hematoma (0.2 percent), pulmonary embolus (0.2 percent), and deep venous thrombosis (0.2 percent). The complication rate was greater among patients undergoing osteotomies, revision procedures, and combined anterior/posterior approaches but was not affected by age or type of scoliosis.

SUMMARY AND RECOMMENDATIONS

●Definition and classification – Adult scoliosis is defined as a lateral curvature of the spine in the coronal plane that is >10 degrees in a skeletally mature patient. The most common causes are de novo scoliosis, associated with degenerative changes, and progression of adolescent idiopathic, congenital, or early-onset scoliosis. (See 'Terminology' above and 'Etiology and classification' above.)

●Clinical presentation – Patients with adult scoliosis often are asymptomatic. Symptomatic patients may present with back pain, postural imbalance with difficulties standing and walking, symptoms of spinal stenosis (neurogenic claudication, radiculopathy), neurologic deficits, and/or concerns about appearance (eg, decreased height, change in posture, asymmetry). (See 'Clinical presentation' above.)

●Evaluation – The objectives of the history (table 3) and examination of the adult with scoliosis are to evaluate clinical findings, determine the etiology (primary degenerative, progression of adolescent idiopathic scoliosis, or secondary to another condition) and factors contributing to pain (if present). (See 'Clinical evaluation' above.)

●Physical examination – Elements of the examination (table 2) include observation of the patient in a standing posture, and the Adam’s forward bend test. A scoliometer is used to measure the angle of trunk rotation (ATR). (See 'Spine examination' above.)

●Radiographs – The initial radiographic evaluation for scoliosis includes standing posteroanterior (PA) and lateral views of the spine on a 36-inch digital cassette. Additional views and/or advanced imaging for patients with symptoms or more severe or progressive scoliosis is usually obtained by the spine specialist. (See 'Radiographic evaluation' above.)

●Diagnosis – Adult scoliosis is a radiologic diagnosis: lateral (coronal) curvature with Cobb angle of >10 degrees (image 1) and complete closure of the iliac crest epiphysis (Risser 5 (figure 8)). The severity of scoliosis increases with increasing Cobb angle. (See 'Diagnosis' above.)

●Natural history and documentation of progression – Educating patients on the natural history of scoliosis aids in shared decision-making regarding treatment choices. We offer lifetime annual/biennial radiographs and clinical follow-up to allow for assessment of any progression of deformity or changes in quality of life. (See 'Curve progression' above and 'Ensuring continuity of care' above.)

●Management – Management of adult scoliosis is individualized according to etiology, severity of symptoms, and quality of life. Primary care management usually includes conservative treatments (eg, analgesic agents, soft bracing, weight loss, four-wheel rolling carts, referral for physiotherapeutic scoliosis-specific exercises). (See 'Symptomatic patient management' above.)

●Referral – Indications for referral to a scoliosis spine specialist include patients who desire regular follow-up monitoring for potential adult curve progression and treatment, persistent pain affecting quality of life despite conservative measures, and red-flag symptoms (eg, neurogenic claudication; radicular pain; progressive weakness, clumsiness, or numbness; loss of bowel or bladder control). (See 'Indications for referral' above.)

●Specialist treatment – Treatment for patients who do not respond to conservative measures may include epidural glucocorticoid injection for radicular pain or surgical intervention for severe deformity.