Spinal Deformity in Adults: More Than Managing ‘Big Kids’

By R. Douglas Orr, MD

To many providers, spinal deformity is synonymous with adolescent idiopathic scoliosis (AIS). Although this is the case in younger age groups, spinal deformity is much more varied and complex in adulthood. This article reviews the special challenges of managing spinal deformity in adults as well as principles and approaches we’ve found effective in these cases at Cleveland Clinic’s Center for Spine Health.

Real differences in adults

The management of AIS centers around curve measurements and involves predominantly the thoracic spine. Pain, although sometimes present, is not a major feature in management. In contrast, in adult deformity we are concerned mostly with the lumbar spine, and pain is the dominant presenting complaint. Curve magnitude and progression generally do not constitute an independent indication for treatment, and there is no role for bracing in adults.

Adult spinal deformity can develop via a number of processes, including:

• De novo deformity due to degenerative change
• Development of symptoms from treated or untreated AIS
• Deformity secondary to trauma
• Iatrogenic deformity resulting from previous surgery

Decision-making in the management of adult spinal deformity is often highly complex and involves weighing a host of treatment approaches and options. In some cases the deformity is incidental to the presenting problem, whereas in others it is a major cause of symptoms.

All about balance

There is wide variation in what is considered “normal” spinal alignment. The human body goes to great lengths to maintain the head’s position directly over the pelvis in both the frontal and sagittal planes. This allows standing and walking with minimal energy expenditure.

We call this spinal balance, and in adults with deformity it is the single most important factor in treatment options and patient-perceived outcome. Patients who are balanced have fewer symptoms and a higher level of function before and after treatment. A primary treatment goal is balance maintenance or restoration.

Assessment at a glance

The first step in assessing the adult with spinal deformity is to identify the dominant presenting complaint. Many patients are unaware that they have a deformity, and they mostly want information on natural history and activities to be avoided or encouraged. Patients most often present complaining of pain. In these cases it is important to get a clear description of the pain and attempt to determine its cause.

Patients with spinal deformity are subject to the same aging-related spine problems as the rest of the population. Most acute back pain in these patients is muscular and self-limiting. Likewise, herniated discs and spinal stenosis can occur in the presence of spinal deformities.

Obtaining a history of the pattern of pain — including onset, location, exacerbating and alleviating factors, and response to treatments to date — will often lead to a presumptive diagnosis. The physical examination should include a neurologic exam as well as assessment of spinal alignment, motion and balance. Hip and knee exams are also often important.

In the acute setting, the indication for imaging should be the same as in a patient without deformity. In the absence of red flags, imaging is not indicated at first presentation. Once imaging is indicated, it should begin with standing X-rays in both the anteroposterior and lateral planes, ideally including the entire spine from occiput to hip joints. Advanced imaging, such as MRI or CT, is indicated for assessing the neural axis and for surgical planning, and CT may be useful for assessing the status of any previous fusion (see Figures 1-4).

Figures 1-4. Imaging studies in a 75-year-old man who presented with increasing axial back pain, neck pain, L5 radiculopathy and an inability to stand upright eight years after an L2-3 posterior fusion. Preoperative lumbar X-rays (Figure 1) showed a degenerative scoliosis and a focal kyphosis above the fusion. A sagittal CT (Figure 2) showed solid fusion from L2 through L5 and a vacuum effect change in the disc spaces at L1-2 and L5-S1. He underwent an anterior interbody fusion at L5-S1, a pedicle subtraction osteotomy at L2 (Figure 3) and a T10-ilium posterior instrumentation and fusion. Good balance was achieved (Figure 4), and six months after surgery he had no pain in his back or neck and the radiculopathy had resolved.

Initial treatment: No special measures required

Whereas surgery is often considered prophylactic in AIS, there is little or no role for prophylactic surgery in adult deformity.

In asymptomatic cases, education and sometimes observation is the mainstay of treatment.

Initial treatment of back or leg pain in an adult with deformity should in most cases be no different than in a person with normal alignment. Acute back pain should be treated with NSAID s, mobilization and core strengthening exercise. Acute radicular pain should be managed expectantly, as most cases will resolve. Claudicant leg pain is managed with exercise, activity modification, medications and possibly interventional therapies such as epidural injections.

Essentially, the spinal deformity becomes a factor in treatment only after appropriate conservative care has failed and surgery is being considered.

Surgery is guided by the deformity’s role in pain

When appropriate nonoperative management has failed and surgery is being considered, the first step is to determine what role, if any, the deformity plays in causing the pain. A patient with a balanced, stable scoliosis with sciatica due to a herniated disc may do very well with just a microdiscectomy. On the other hand, a patient with a fixed deformity who is unable to stand with head balanced over hips will not benefit from an operation that does not restore balance.

If the dominant symptoms result directly from the deformity, surgery must address the deformity. In general, any patient who is no longer in balance will need to have the deformity corrected and stabilized. These are generally complex major procedures with significant risks and a prolonged recovery. In some medically fragile patients, the risks of surgery to correct deformity are simply too high for it to be a viable option.

Limited procedures: Don’t believe all you were taught

Many spine surgeons were taught that limited surgery has no role in cases of deformity and that an all-or-nothing approach is needed. I no longer believe this, as I see a role for limited surgery in certain appropriate situations. In a patient with a balanced spine in whom the pain generator can be localized, there is a role for focal surgery to address just this problem. For example, in a patient with spinal stenosis, a degenerative spondylolisthesis and a balanced degenerative scoliosis, treatment of just the stenosis and spondylolisthesis may be a very good option.

Tailor the multiple technique options

Surgery to correct spinal deformity is a highly complex undertaking that many spine surgeons opt not to offer as part of their practice. These operations generally involve long incisions and extensive instrumentation to correct and stabilize the spine. Many different techniques can be used, with no single technique appropriate for all situations. Anterior, posterior, combined and minimal-access approaches may be used, and each surgeon should employ the techniques that he or she performs best for the given clinical situation. Outcomes studies show that as long as a balanced, stable spine is achieved, outcomes are equivalent regardless of technique.

Less-invasive surgical techniques have attracted much interest in recent years, and some show a lot of promise. In other cases, less-invasive techniques have produced inferior results compared with standard techniques and are no longer in use. No studies have directly compared newer to traditional procedures. Overall, it appears that minimal-access techniques shorten recovery time but have not shown a benefit over the longer term. These techniques are often a very good option in selected patients, and their role in the treatment of spinal deformity continues to evolve.

Stakes of proper management are high

There is a wide range of treatment options for spinal deformity in adults, and no single approach works for all problems. Patients with symptomatic spinal deformity should seek a clinician with experience in treating these problems — ideally one who can provide the full range of options. An inappropriate initial surgical choice carries a significant risk of worsening the deformity. It is not uncommon for patients to undergo multiple procedures to treat a deformity, even at the most experienced centers. While spinal deformity can lead to debilitating pain, its successful treatment can dramatically change patients’ quality of life.

Dr. Orr is a spine surgeon in the Center for Spine Health and a staff physician in the Department of Orthopaedic Surgery.