Surgery For Adult Scoliosis: When and Why
Scoliosis, a curvature of the spine occurs most often in older children and teenagers. But it can develop in older adults with serious complications. The cause is usually age-related degenerative changes in the spine. Sometimes there is no known cause. In this study, surgeons from the Department of Neurosurgery at the University of Virginia examine how often scoliosis occurs in older adults and the treatment needed.
Adults over the age of 60 with spinal deformity were included in the investigation. Patients were examined thoroughly with a detailed personal and family history, physical exam, and additional neurological exam. A full-length spine X-ray was taken to show the complete scoliosis. Each patient filled out a series of surveys to judge pain levels, function, and disability.
The patients were divided into two groups based on the chosen treatment approach. The nonoperative management included physical therapy, steroid injections, antiinflammatory drugs, and narcotic pain relievers. The operative group had spinal surgery to correct the spinal deformity.
Conservative care was advised for everyone first. Many patients have had nonoperative care that didn't help. But the treatment may not have been enough or inconsistent at best. Entering a formal pain management program often makes the difference. And addressing issues such as deconditioning can be very helpful.
But failure to reduce pain, deformity, weakness, and bowel/bladder problems was an indication that surgery was needed. The decision to have surgery was not taken lightly. Complications from this type of surgery can be serious in this age group. The patients and surgeons talked together at length before taking this step.
All patients were advised that surgery can provide about a 50 per cent improvement. In other words, it's not a cure, and it doesn't result in a 100 per cent reduction of pain. There's no way to predict how much bowel or bladder function will improve (or if it will even improve at all). The majority of patients stayed in the nonoperative group. Out of 319 patients, only 74 had surgery.
Those who had surgery had much greater disability compared with the patients who stayed with nonoperative care. The surgical group were more likely to have severe back and/or leg pain, leg weakness, and loss of normal bowel and bladder function. About 15 per cent of the patients who were originally in the nonoperative group crossed over to the operative group. These patients had surgery during the follow-up portion of this study.
The authors concluded that pain, neurologic symptoms, and the loss of function that occurs because of these problems are the most common reasons to pursue surgery. Older adults should be encouraged to try an adequate course of nonoperative care before considering surgery.
All the pros and cons of surgery should be discussed. The patient makes the final decision, but the surgeon plays an important role in the counseling and management portion of treatment. It's a difficult and complex decision that must take many factors into consideration.
This study points out the importance of three of those factors: pain, weakness, and deformity. Surgery is more likely in the presence of these three things. Further study is needed to identify other factors in the decision-making process. Evaluation of the long-term results may provide additional helpful information for future patients facing this difficult treatment decision.
Justin S. Smith, MD, PhD, et al. Neurological Symptoms and Deficits in Adults with Scoliosis Who Present to a Surgical Clinic: Incidence and Association with the Choice of Operative Versus Nonoperative Management. In Journal of Neurosurgery:Spine. October 2008. Vol. 9. No. 4. Pp. 326-331.
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