By Dr Jeb McAviney
BSc., MChiro., MPainMed., FCBP
Adolescent Scoliosis in the Adult (ASA) &
Degenerative De-Novo scoliosis (DDS)
Adult Scoliosis
 ASA is pre-existing AIS but
in adulthood
 DDS is a new development
of scoliosis in adulthood.
 The primary concern in
most adult cases is Pain
 Progression and Aesthetics
are also considerations
ASA 1
• Usually smaller flexible curves in
younger adults 18-30 years old
• Posture and Cosmetic issues are
the main problem.
• Pain can be an issue particularly in
unbalanced curves
• Potential reducibility in both
abnormal posture and Cobb.
ASA 2
• Usually larger more rigid curves in
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•
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•
middle aged adults 30-40
Pain and posture equally issues.
Pain can be an issue even in
balanced curves.
Often start to see early
degenerative changes
Intervention in ASA 2 could
potentially to stop progression to
ASA 3
ASA 3
• Usually large, rigid curves in older
•
•
•
•
adults 40+
Pain is the primary issue.
Moderate to severe degenerative
changes present.
Most commonly lumbar curves.
No previous history of scoliosis
could indicate Degenerative De
Novo Scoliosis DDS.
Degenerative De-Novo Scoliosis (DDS)
• New curve in adult developed as a
result of degenerative instability.
• Usually lumbar curve, unbalanced.
• Large, rigid curves in older adults 50+
• Pain is the primary issue.
• Moderate to severe degenerative
changes present.
Prevalence of Adult Scoliosis in Back
Pain
Perennou et al;
 671 LBP patients:
 7.5% had evidence of
scoliosis.
 Prevalence of scoliosis
increased with age;
 2% before 45 years (most
likely ASA)
 15% after 60 years
(probably DDS)
Prevalence of Adult Scoliosis in Back
Pain
Robin et al;
 554 LBP patients
 Aged 50 to 84
 30% scoliosis >10°
At 5 year follow up
 40% scoliosis >10°
 Additional 10%
“a significant number of older people have an adult scoliosis”
and its prevalence and progression is directly related to
advancing age”
“Adult Scoliosis - A Quantitative Radiographic and
Clinical Analysis”, Schwab et al. Spine 2002,
Schwab’s research identifies
these radiographic parameters
as important:
• Level of regional balance.
• Instability
• Pathologic mechanical loads
of the spinal elements
“Adult Scoliosis - A Quantitative Radiographic and
Clinical Analysis”, Schwab et al. Spine 2002,
He identifies these correlations
with pain:
• Lateral vertebral olisthy,
(side slip)
• L3 and L4 endplate obliquity
angles,
• Decrease in lumbar lordosis,
• Increased thoraco-lumbar
kyphosis
“Adult Scoliosis - A Quantitative Radiographic and
Clinical Analysis”, Schwab et al. Spine 2002,
• The Cobb angle of the
scoliotic deformity had no
statistically significant
correlation to the VAS.
• Early intervention in a
middle-aged adult with
scoliosis may be preferable
to treating advanced
deformity in that same
person once he or she has
become elderly.
“Correlation of Radiographic Parameters and
Clinical Symptoms in Adult Scoliosis”
Glassman, et al. Spine 2003
298 patients
The purpose of the study was
to correlate radiographic
measures of deformity with
patient-based quality of life
and health status
assessments in adult
scoliosis.
“Correlation of Radiographic Parameters and
Clinical Symptoms in Adult Scoliosis”
Glassman, et al. Spine 2003
The most significant findings
were:
 Positive (anterior) Sagittal
Balance
 Greater pain
 Diminished physical function
 Poorer self image
 Poorer social function
“Correlation of Radiographic Parameters and
Clinical Symptoms in Adult Scoliosis”
Glassman, et al. Spine 2003
 Coronal shift > 4 cm
 Poorer function
 Greater pain
 Compared to patients with a
coronal shift < 4 cm.
“Correlation of Radiographic Parameters and
Clinical Symptoms in Adult Scoliosis”
Glassman, et al. Spine 2003
Key Points
 Positive (anterior) sagittal
balance predicts clinical
symptoms in adult spinal
deformity.
 Thoracolumbar and lumbar
curves have worse outcomes
than thoracic curves.
 Significant coronal imbalance
was associated with pain and
dysfunction.
Progression of Adult Curves
• Progression in ASA 1&2 is generally not a major concern unless the
curve is already very large >60 deg
• Danielson and Nachemson in Spine 2003 found that 36% of
adolescents with scoliosis had progressed by more than 10° after 22
years.
• ASA 3 and DDS can become moderate to severely progressive due
to degenerative instability and or hormonal influence.
• The most progressive DDS cases often have osteoporosis as a co-
morbidity
Progression of Adult Curves
Spinal
Degeneration
Boney
adaptation
(Wolffs Law)
Scoliosis
Progression
Soft tissue
integrity lost
Functional
unit instability
increased
Natural History of Progressive Adult Scoliosis
Marty-Poumarat et.al. Spine 2007
Two main types were identified:
1) Type A
• Adolescent scoliosis
• Progresses after skeletal maturity
Natural History of Progressive Adult Scoliosis
Marty-Poumarat et.al. Spine 2007
Two main types were identified:
2) Type B
• Progresses late in adulthood:
• Pre-existing stable adult scoliosis
with late progression
• De novo late-onset scoliosis.
Natural History of Progressive Adult Scoliosis
Marty-Poumarat et.al. Spine 2007
Progression was measured at a
liner rate specific to each curve.
“We did not find any correlation
between the initial Cobb angle and
slope of progression in the overall
population.”
Natural History of Progressive Adult Scoliosis
Marty-Poumarat et.al. Spine 2007
Role menopause plays
 In 8 women with type A scoliosis with
a long progression comprising
menopause, no change of slope was
observed at menopause.
 Patients with type B scoliosis were all
women and exclusively presented a
lumbar or thoracolumbar single curve.
 In type B, 11 out of 20 of these
patients progressed at the time of
menopause.
Natural History of Progressive Adult Scoliosis
Marty-Poumarat et.al. Spine 2007
Summary
 The progression of adult scoliosis is linear. It can be used to
establish an individual prognosis.
 Two main types exist:
 Adolescent scoliosis, which continues to progress (type A)
ASA 1&2
 Late onset scoliosis, either pre-existing stable adolescent
scoliosis or de novo (type B). ASA3 & DDS
 Menopause constitutes a period of deterioration for type B.
Progression of Adult Curves
Type BM
Soft tissue
integrity lost
Menopause
Boney
Degeneration
Functional
unit instability
increased
Boney
adaptation
(Wolff’s Law)
Rotational
Subluxation
Scoliosis
DDS Development
50 yr old woman minor LBP
5 years latter developed DDS
Adult Scoliosis Treatment
Increased Life Expectancy vs. Long term Quality of Life
• Degenerative pathologic conditions in aging persons are increasingly of
concern in regards to long term quality of life and independence
• The focus of medical treatment in Adult cases is usually on regional
degenerative pathologic conditions such as stenosis, spondylolisthesis, disc
degeneration etc. rather than the deformity itself!
 “Although the common degenerative conditions of the spine are frequently
treated as focal pathologic states, it appears intuitive that deformity of the
spinal column, by altering the mechanical loading conditions, can
accelerate the degenerative cascade.” Schwab et al, Spine 2002
Adult Scoliosis Treatment
Rigid vs. Dynamic Orthosis for Treatment
Rigid
Dynamic
 Muscle Atrophy in unstable
 Muscle rehabilitation and




system
Limitation of movement
Self image issues
Comfort issues
Useful in Neuro-degenerative
cases





stabilization
Allows movement
Not visible under clothing
Relatively comfortable
Suitable for long term use
Not suitable for Neurodegenerative cases
Goal is improvements in Sagittal and Coronal balance not a forced reduction
in Cobb angle
Corrective Movement & Spinal Loading
SpineCor Adult Treatment
LEFT LUMBAR
CLASSIFICATION
CORRECTIVE
MOVEMENT
BRACE
IN PLACE
SpineCor and Sagittal Balance
Corrective movement for
Anterior Sagittal Balance
 First have the patient
stabilise their lordosis by the
contraction of abdominal
and gluteus muscles.
 Second translate the base of
the thorax slightly forwards
and upwards.
SpineCor Adult Brace
Examples of Adult treatment
Patient A
 26 year old female,
 Painful adolescent idiopathic
scoliosis as an adult (ASA1).
 Pain 7/10.
 8 to 12 hours for 3 months
 Gradual relief of pain to 2/10.
 32 deg right thoracic scoliosis.
 Improvement of 8 degrees to 24
deg.
 Relief of 1-2/10 and spinal
correction have been maintained
for over 2 years .
Courtesy of Dr Tom Pappas
Examples of Adult treatment
Patient B
 47 year old female
 Degenerative De-Novo Adult
Scoliosis. (DDS)
 Pain 7/10.
 Immediate relief of pain to 3/10.
 A 40 deg degenerative lumbar
scoliosis.
 Improvement of 7 degrees to 33
deg.
 Pain relief of 0-3/10 maintained
for over 2 years
 Note the improved left lateral shift
showing “spinal off loading”.
Courtesy of Dr Tom Pappas
Thank you