What is it?
Degenerative scoliosis or adult scoliosis is a progressive pathology of the spine that first involves the lumbar spine and then the entire spine. It is characterized by loss of physiological lumbar lordosis and progressive flattening of the spinal kyphosis to a pattern of sagittal imbalance with activation of compensation mechanisms (pelvic anteversion, hip extension and knee flexion) to maintain the line of sight to the horizon. Disc degeneration, degenerative spondylolisthesis, and lumbar stenosis can all be encapsulated within degenerative scoliosis. The resulting mechanical instability may be associated with pain and radicular disorders, difficulty walking with highly variable clinical and developmental characteristics.
Which are the symptoms?
Low back pain may be associated with radicular or multi-metacular irradiation to the lower limbs. Progressively, the upper body is projected forward and the compensation mechanisms are activated, resulting in reduced walking autonomy.
The inability of patients to walk independently or maintain an upright posture is due to insufficient support of the vertebral column and the posterior musculature. The greater the sagittal imbalance, the greater the effort required by the patient to restore balance to the body.
- neurogenic claudication
How is it diagnosed?
The radiological examinations to be requested from the patient to diagnose adult scoliosis are as follows:
Radiograph of the entire column in orthostasis in 2 projections, including the femoral heads on the long radiograph:
- Cobb degrees of thoracic and lumbar curvature in the coronal (scoliosis) and sagittal (kyphosis and lordosis) planes;
- study of spino-pelvic parameters (pelvic incisiveness - pelvic tilt - sacral tilt) to assess sagittal balance;
- Severity index for possible presence of spondylolisthesis with low or high dysplasia.
Rx in dynamic projections:
- lumbar flexion/extension to identify possible segmental instability;
- Lateral flexion in the frontal plane of the thoracic and lumbar spine to assess the flexion index;
- Oblique X-ray if spondylolysis is suspected. Whole spine and lateral flexion radiographs allow evaluating the severity and stiffness of the deformity and classifying it morphologically (Lenke and Roussoly classification).
MRI of the thoracic and lumbar spine:
- Canal stenosis (myelographic effect useful)
- Myoradicular disc/vertebral compression
- Spongiosa oedema (neoplastic or traumatic pathology)
- degree of disc degeneration (Pfirrmann classification 1-5)
- inflammatory oedema of the vertebral limiting factors ( Modic classification)
- endocanal joint cysts
- CSF accumulations and fistulas
- septic masses
- neoplastic masses
- abnormalities of nerve structures (subdural and/or intramedullary)
CT: assessment of canal diameter / pedicle morphology and size / isthmus defects (spondylolysis or lengthening / fractures) / gaseous degeneration of the disc / degeneration degree of joint facets / osteophytes - endocanal calcifications / mobilisation and/or malpositioning of synthesis means (screws - interarticular cell) / assessment of arthrodesis or pseudarthrosis from previous operations / osteolysis and secondary and/or primary structural changes
Any additional diagnostic examinations:
- Neurophysiological examination (motor and sensory evoked potentials and/or EMG)
How is it treated?
The non-surgical treatment pathway consists of anti-inflammatory drug therapy, analgesic therapy, corticosteroid therapy, infiltrative therapy when indicated, physiotherapy when indicated, and modification of physical activity that can cause strain on the spinal axis.
Patients with degenerative scoliosis are indicated for surgical treatment if disabling thoracic and/or lumbar pain with or without irradiation to the lower limbs does not respond to conservative treatment (medical therapy - physiotherapy - pain therapy) for at least 6 months.
There is a neurogenic claudication due to stenosis (<500 m), lower limb strength and/or sensibility deficit, or sphincter disorders and reduced walking autonomy or inability to maintain an upright position.
The main goal of surgery is to correct the deformity, sagittal and/or coronal imbalance, if present, to limit the progression of the pathology and reduce pain, and improve quality of life.
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