Treatment of Dextrocurvature of the Spine
Surgical decompression and fusion is the recommended treatment for symptomatic dextrocurvature of the spine when associated with stenosis and spondylolisthesis in patients who desire surgical intervention. 1
Understanding Dextrocurvature
Dextrocurvature refers to a lateral curvature of the spine toward the right side. This is a form of scoliosis, which is defined as a lateral spinal curvature with a Cobb angle of 10° or more. The management approach depends on several factors:
- Type of curvature
- Underlying cause
- Severity of symptoms
- Presence of associated conditions (stenosis, spondylolisthesis)
- Patient's age and skeletal maturity
Classification of Adult Scoliosis
Adult scoliosis can be categorized into four major types 2:
- Primary degenerative scoliosis - Based on disc/facet joint arthritis affecting structures asymmetrically
- Idiopathic adolescent scoliosis - Progressing into adulthood
- Secondary adult curves:
- Due to oblique pelvis, leg length discrepancy, or hip pathology
- Associated with metabolic bone disease (osteoporosis) with asymmetric arthritic disease
Treatment Algorithm
1. Non-Surgical Management (Initial Approach)
- Physical therapy focusing on core strengthening
- Non-narcotic analgesics
- Patient education
- Conservative management for at least 4 weeks before considering invasive procedures 3
2. Interventional Procedures
- Epidural steroid injections for patients with radiculopathy who have failed conservative management 3
- Transforaminal epidural steroid injections (TFESI) for radicular pain
3. Surgical Management
For patients with:
- Progressive curvature
- Neurological symptoms
- Significant pain unresponsive to conservative treatment
- Stenosis with spondylolisthesis
Recommended Surgical Approach:
- Surgical decompression with fusion is the treatment of choice for symptomatic stenosis associated with spondylolisthesis 1
- The fusion technique should be individualized based on:
- Patient's anatomy
- Surgeon's experience
- Patient's preferences and concerns 1
Surgical Options:
- Posterior approach: Effective for curves between 40-70 degrees 4
- Combined anterior-posterior approach: May be considered for rigid curves, though evidence suggests posterior-only approaches can achieve similar radiographic correction 4
- Laminoplasty: For cervical dextrocurvature with associated myelopathy 1
Special Considerations
Curve Progression Risk Factors
- Skeletal immaturity
- Larger initial curves
- Rapid growth periods 5
Monitoring
- After skeletal maturity, curves greater than 30° should be monitored for progression 5
- Follow-up intervals may be as short as 4 months in skeletally immature patients 5
Surgical Complications to Monitor
- Segmental motor paralysis (particularly at C5 level in cervical procedures) 1
- Post-laminoplasty kyphosis (reported incidence of 8-10%) 1
- Higher complication rates with staged anterior-posterior surgeries (45%) compared to posterior-only approaches (24%) 4
Key Pitfalls to Avoid
Delayed treatment: Continuous asymmetric loading can transform a reversible spinal curvature into a permanent deformity 6
Inadequate assessment: Failure to identify the curve type, degree of angulation, vertebral rotation, and extent of spinal involvement can lead to inappropriate treatment selection 5
Overlooking associated conditions: Scoliosis may be associated with underlying congenital, developmental, or neurological abnormalities that require specific management 5
Inappropriate surgical approach: The evidence suggests that posterior-only approaches can be as effective as combined approaches for curves between 40-70 degrees, potentially avoiding higher complication rates of combined procedures 4
The management of dextrocurvature requires careful evaluation of the specific characteristics of the curve and associated conditions, with surgical decompression and fusion being the recommended approach for symptomatic patients with stenosis and spondylolisthesis who desire surgical intervention.