Definition Adult spinal deformity is defined by the Scoliosis Research Society as a spinal deformity with any etiology in a skeletally mature patient.
Scoliosis is defined as lateral deviation of the normal vertical
line of the spine of greater than 10 when measured on radiographs. Indications and Treatment Goals
The primary goals in treating adult spinal deformity are to gain
spinal balance, halt the progression of deformity, reduce pain, and improve the patients healthrelated quality of life (HRQL). Treatment should improve the patients outcome above the natural history of the disease and avoid any deleterious long-term effects. The only study of the natural history of adult scoliosis evaluated patients with untreated adolescent idiopathic scoliosis. At a mean follow-up of 51 years (range, 44 to 61 years), the authors reported mean cobb angles of 84, 89, and 49 for the thoracic, thoracolumbar, and lumbar spines, respectively. The study showed no difference in survival rates compared with the general population Patient Evaluation
Clinical Evaluation Low back pain is the most common
symptom reported by patients with adult spinal deformity. Symptoms of low back pain are also common in the general population and cannot be immediately attributed to scoliosis. A thorough history and examination is necessary to rule out other potential causes In general, patients younger than 40 years with adult scoliosis present with symptoms similar to those of younger patients with adolescent idiopathic scoliosis. Typically, a patients primary concerns are the probability for curve progression and the potential for long-term sequelae, poor cosmesis, and low back pain. The etiology of these symptoms should be evaluated in a manner similar to that used in evaluating patients without scoliosis. In addition to a thorough neurologic evaluation, a physical examination should be performed to evaluate gait and standing balance. Observing the patients gait permits an evaluation of spinal balance while in motion. Many patients with scoliosis may stand erect in sagittal and coronal balance; however, ambulation causes fatigue, which may result in positive sagittal imbalance. Because patients with fixed sagittal imbalance often pitch forward progressively when ambulating any distance, hip and knee range of motion should be closely examined. In general, adults with spinal deformity should be clinically evaluated in a manner similar to that used for patients presenting with a spinal disorder. The source of the patients complaint, such as low back or leg pain, should be evaluated first. The unique dimensions of a deformity, whether it is scoliosis or fixed sagittal imbalance, should then be considered in the overall evaluation and treatment plan. Radiographic Evaluation
Standing, 36-inch PA and lateral radiographs are needed to
evaluate adult spinal deformity. The knees should be fully extended for the lateral radiograph to ensure accurate assessment of sagittal balance. The cervical, thoracic, and lumbar spines as well as the pelvis and hip joints should be visible. Cobb angles, coronal and sagittal balance, and pelvic incidence should be measured and recorded (Figures 1 through 3). Radiographs taken with the patient bending can be used to assess the flexibility of coronal plane deformities and may aid in surgical decision making, especially in younger adults who can be classified with the Lenke system Types of Adult Spinal Deformity
Any spinal disorder or disease that leads to scoliosis or
coronal or sagittal imbalance in a skeletally mature patient is considered an adult spinal deformity. The most common categories are adult idiopathic scoliosis, adult de novo scoliosis, and fixed sagittal imbalance. Adult Scoliosis Adult idiopathic scoliosis is defined as scoliosis in a skeletally mature patient that existed in childhood or adolescence. Adult de novo scoliosis, or degenerative scoliosis as it is commonly termed, is a condition that did not existent before skeletal maturity and developed in adulthood. The overall prevalence of adult scoliosis increases with age. Adult degenerative scoliosis predominantly develops in the thoracolumbar spine however, compensatory curves can also develop in the thoracic spine. The incidence of low back pain in patients with untreated adolescent idiopathic scoliosis (mean age, 66 years) was higher than in a matched cohort (67% versus 35%). Most of the patients rated the intensity of pain as low or moderate Nonsurgical Treatment There is little consensus and only weak evidence for the effectiveness of any one nonsurgical treatment method for adult scoliosis and adult deformity in general. Typically, the recommended nonsurgical treatment is based on the chief symptoms reported by the patient. If low back pain is the main symptom, a structured physical therapy program based on the patients physical capabilities is recommended, with emphasis on core strengthening and spinal balance. Surgical Treatment The surgical decision-making process for adult scoliosis is difficult. The procedures are often complex, full recovery can take up to 1 year, and complication rates as high as 20% have been reported in older patients. Patients are often confused about their prognosis and fearful of the potential effects of scoliosis on their general health and appearance. Taking time to discuss the natural history of the condition Curve Correction Although there is evidence that coronal imbalance greater than 4 to 5 cm correlates with a reduced health status, there is no evidence that surgical correction of coronal imbalance correlates with improved outcomes. The most important predictor of outcomes is spinal sagittal balance however, restoring lumbar lordosis to achieve sagittal balance often requires some degree of curve correction. Selection of Fusion Levels Selecting the appropriate cephalad and caudad levels for fusion remains an area of controversy. In a patient younger than 40 years with adult idiopathic scoliosis, the selection of fusion levels correlates more closely with recommendations for adolescent idiopathic scoliosis. Approach In the traditional treatment of scoliosis, anterior release combined with or without anterior fusion was believed to improve curve correction and restore alignment, especially in patients with a rigid curve. However, the anterior thoracolumbar approach can be associated with morbidity. Decompression Up to 64% of patients with adult scoliosis present with reports of leg pain associated with stenosis. Adequate neural decompression is the first treathment priority. Limited Decompression and Fusion The role for limited decompression without fusion and decompression with limited fusion in adult scoliosis is not well defined. Typically, the patient being considered for treatment with a limited approach is older, has unilateral or bilateral leg pain symptoms secondary to lumbar stenosis, and minimal or no back pain. The goal of a focused treatment is to address the primary symptomatic pathology (lumbar stenosis) without causing iatrogenic instability and rapid curve progression.e first treatment priority. Fixed Sagittal Imbalance Syndrome Fixed sagittal imbalance is defined as radiographic sagittal imbalance of more than 5 cm. This syndrome has multiple etiologies (Table 1), Treatment The recommended surgical treatment of fixed sagittal imbalance is dependent on the amount of positive sagittal imbalance, the degree of flexibility of the deformity, and whether the kyphosis is focal (limited to a few spinal segments; for example, posttraumatic kyphosis) or multilevel (involving several spinal segments; for example, Scheuermann kyphosis) Interbody Fusion Interbody fusion is limited to use in patients with minor sagittal imbalance (6 to 8 cm). Two thirds of lumbar lordosis occurs through the L4-L5 and the L5-S1 segments. Lumbar lordosis can be improved by restoring the disk height at L4- L5 and L5-S1 through the use of structural interbody allograft or cages. Because of the technical challenges and potential complications of inserting larger grafts or cages through the posterior approaches (transforaminal or posterior lumbar interbody fusions), anterior lumbar interbody fusion is preferred by many surgeons as a more effective method of regaining lordosis. For example, in a patient with a prior thoracolumbar fusion extending to L4 with disk degeneration and sagittal imbalance of 8 cm, an anterior lumbar interbody fusion at L4-L5 and L5-S1 may restore enough lordosis to obtain sagittal balance. Smith-Petersen Osteotomy Smith-Petersen osteotomies are usually performed at multiple levels and can restore as much as 10 of lordosis per level depending on the amount of disk mobility. A Smith-Petersen osteotomy will not be successful if there is anterior fusion, and/or will provide minimal correction if there is minimal disk height associated with large osteophytes. Smith-Petersen osteotomies can be added to the anterior lumbar interbody fusion or used in conjunction with a pedicle subtraction osteotomy to increase the magnitude of lordosis correction. Smith-Petersen osteotomies are commonly used to treat Scheuermann kyphosis, lesser degrees of thoracolumbar kyphosis, and can be used as a method of restoring lordosis and improving correction in thoracolumbar scoliosis. Pedicle Subtraction Osteotomy A pedicle subtraction osteotomy is indicated in patients with more severe sagittal imbalance (> 12 cm). A correction of 30 to 35 can be expected in the lumbar spine and 25 in the thoracic spine. These osteotomies are effective in treating focal kyphosis and can be used to treat severe scoliosis, with an asymmetric correction in the sagittal and coronal planes Vertebral Column Resection Vertebral column resections are indicated for the corection of rigid, angular kyphosis in the thoracic spine; severe rigid scoliosis; congenital kyphosis; hemivertebrae resection in the thoracic and lumbar spines; and kyphotic deformity associated with tumor, fracture, or infection in the thoracic spine. Neuromuscular Adult Scoliosis Neuromuscular adult scoliosis covers a broad range of conditions, including cerebral palsy, spinal muscle atrophy, Duchenne muscular dystrophy, poliomyelitis, and paraplegia. Adult-onset conditions such as multiple sclerosis and Parkinson disease, which cause general weakness and balance problems, can also cause neuromuscular-type deformities. The deformity can occur in any region of the spine, with the patient presenting with kyphosis, lordosis, and/or sagittal and coronal imbalance. Often, there is a long sweeping type deformity, which may be flexible in the young adult patient. The deformities associated with multiple sclerosis and Parkinson disease may be flexible at the early onset of the disease in middle-aged and older adults but may become progressively rigid with time. Pain, halting deformity progression, and achieving spinal balance are the goals of treatment. In a patient who is confined to a wheelchair, sitting balance is key to allowing efficient use of the upper extremities and preventing skin breakdown. Because a high rate of surgical complications occurs in this group of patients, proper counseling regarding expected outcomes is important. In one of the few studies evaluating spinal surgery in patients with Parkinson disease, the rate of revision surgery was 86% and the infection rate was 14%. Intraoperative Neurophysiologic Monitoring The evidence in support of the routine use of intraoperative neurophysiologic monitoring during the treatment of spinal deformity has strengthened. Its use aids in the early detection of impending spinal cord injury and may prevent worsening postoperative morbidity. A study of more than 1,000 patients (mean age, 14 years) surgically treated for adolescent idiopathic scoliosis showed that changes in transcranial electric motorevoked potentials were detected earlier than changes in somatosensory-evoked potentials Twenty-six patients had decreases in amplitude of 65% in transcranial electric motor-evoked potentials during posterior instrumentation and corrective maneuvers. Nine (35%) of these patients (0.8% of the study group) had a transient motor or sensory deficit postoperatively, all of which were detected by transcranial electric motorevoked potentials. Challenges
The Aging Spine
The rate of complications in adult deformity surgery increase as the complexity of the surgery increases. As the population ages, there has been an increase in the number of older patients who are being surgically treated for major spinal deformities. Many complications are related to medical comorbidities and osteoporosis. The rate of major complications in patients older than 60 years was 20% in one series, with the rate of complications significantly increasing in patients older than 69 years. Corrective Osteotomies Pedicle Subtraction osteotomies and vertebral column resections allow the correction of rigid sagittal and coronal deformities, but there are increased risks with these techniques. The incidence of neurologic deficits was as high as 11% in one study, but most of the injuries were limited to the nerve root levels and eventually resolved. The rate of pseudarthrosis with pedicle subtraction osteotomies was reported as high as 28% at 5-year follow-up; however, after revision surgery the HRQL measures improved and were not significantly different from those of patients without psuedoarthosis. Vertebral column resections are associated with a higher rate of neurologic deficits and intraoperative neurophysiologic monitoring changes Pseudarthrosis Pseudarthrosis continues to be a major challenge and is one of the main complications in multilevel, adult deformity surgery. With longer term follow-up, the rate of pseudarthrosis increases. It has been reported to be 17% in one large series and as high as 24% in a recent report, with only 25% of the cases of pseudarthrosis detected within the 2- year follow-up period. Future Directions Over the next several years there will be a demand for better- quality scientific evidence that surgical treatment in adult spinal deformity is making a clinically significant improvement in the lives of patients. Large clinical series have shown that sagittal balance is a key predictor of improvement in HRQL. As the understanding of the role of pelvic parameters in determining sagittal balance increases, orthopaedic surgeons may become more adept at individualizing surgical interventions to restore spinal balance. The treatment of adult spinal deformity is complex. The indications for surgical treatment should not be based on radiographs alone. Many patients can tolerate high magnitude curves and function well. Treatment recommendations should be individualized and the impact of the deformity on the patients daily function and quality of life should be considered.