Adult Scoliosis

Overview  |  Signs and Challenges  |  Conservative Treatment  |   Surgical Correction

Correction of Spinal Deformity - Surgery for Adult Scoliosis

Reasons Surgery Might Be Considered

  Few patients with adult scoliosis will ultimately require surgery. When necessary, the goals of surgery are to stop curve progression, stabilize the spine, establish correct spinal balance, decrease back and leg pain, and increase function with as little surgery and as few complications as possible. Patients who require surgery to straighten, stabilize and fuse their spinal curvature are patients with:

• Increasing curvature over time (it will continue to get worse)
• Unstable spine that hurts despite conservative care
• Nerve compression causing pain, numbness, or weakness
• Spinal imbalance which is painful or progressive
• Large curve which will progress (better to do these earlier while health is good and before osteoporosis starts or worsens)

Surgical Options and Results

  If the main problem is leg pain caused from a disc herniation, this can usually be taken care of with a small surgery to remove the disc fragment and decompress the nerve. A large procedure to correct the scoliosis and fuse the spine is not necessary. Sometimes leg pain is caused by bone spurs that are compressing the spinal nerves. This is spinal stenosis. If stenosis is the problem, the solution usually will require removal of the offending bone spurs to get pain relief. If adequate bone is to be surgically removed to decompress the pinched nerves (laminectomy), the spine is often rendered somewhat unstable in the process. Back pain will increase, leg pain may return, and the spinal curvature will get bigger if the spine is not fused at the same time. In these cases, correction of the curve and fusion with bone graft and instrumentation is required to stabilize the spine and prevent what would be a certain need for future surgery.

  When back pain, progressive deformity, or spinal imbalance are primary factors, the curve should be straightened and fused. The amount of correction obtained with surgery is sometimes limited compared to the corrections seen in the pediatric patients. This is due to increased spinal stiffness in adults.

Surgical Technique to Correct Scoliosis

  Once the decision for surgery has been made, the operative plan is formulated. Patients are routinely asked to donate blood before surgery to be stored and used during their surgery. The spinal cord function is usually monitored throughout the surgery to make sure there is no compromise to spinal cord function. Bone graft material and spinal instrumentation may need to be arranged for ahead of time. Surgery to correct adult scoliosis is the most challenging surgery done in orthopedics, and is likely among the most complex and demanding surgeries of any kind being performed today. This type of surgery requires at least one assisting surgeon and often a surgical team, and can take from 3-14 hours to accomplish.

Anterior Surgery

  If the spine must be fused anterior or from the front, a thoracic or general surgeon will be a part of the surgical team to safely mobilize the great blood vessels off the spine where the spine surgeon will work. The incision may be through the side of the chest, through the side of the abdomen, or through the front of the abdomen, depending on what is needed at the time of surgery. The purpose of anterior surgery is to remove the discs, and fill the space with bone graft or Bone Morphogenetic Protein (see below). This serves to improve the correction which can be achieved and improve the reliability of the fusion.

  Sometimes the spine is "instrumented" from the front, meaning that screws are placed into the vertebra and attached to a rod that will correct the deformity and stabilize the spine.

  More recently, the thoracoscope has been used in spine surgery. We can now remove discs from the thoracic spine and insert bone graft without making a large incision. All of the work is done through a few one-inch incisions on the side of the chest.

Posterior Surgery

  Most of the correction of scoliosis is done from the back of the spine. If nerves are compressed by bone spurs or a disc herniation, the offending structures can be removed to allow more room for the nerves. The spine is then "instrumented" by the placement of hooks or screws that attach to the vertebrae. These hooks and screws are then attached to rods that span the curve. The instrumentation is then distracted, compressed, or rotated in order to correct the spinal curvature. Without instrumentation, the curve cannot be corrected.

  Bone graft is always used in scoliosis surgery. The spine must be fused in its new corrected and straightened position. The graft most commonly comes from the patient's own pelvis. Sometimes bone-bank bone is used when there is not sufficient bone available form the patient. Newer uses for Bone Morphogenetic Protein include posterior scoliosis fusions.

RESULTS FROM SURGERY

  Adult patients who undergo major spinal surgery to correct their scoliosis generally do well. Pain is greatly improved or eliminated in the majority (80% in our series). The fusion is successfully achieved and the correction maintained long-term in 80-95% of people who have mild to moderate scoliosis corrected with or without nerve root decompression. In our series of recent patients, curve correction is averaging 67 – 79%, depending on the type of scoliosis.

  Complications can occur however, such as failure of the spine to solidly fuse, failure of the spinal hardware (<2%), infection (2-4%), nerve injury (<1%), medical complications, and others. The patients who are at greatest risk for complications are smokers, people taking steroids and those with severe osteoporosis or poor nutrition.

Overview  |  Signs and Challenges  |  Conservative Treatment  |   Surgical Correction