From the Guidelines
The best evidence-based management of adult spinal deformity involves a stepwise approach starting with conservative measures before considering surgical intervention, with a focus on individualized treatment based on the patient's specific condition, age, comorbidities, and functional goals. Initial management should include physical therapy focusing on core strengthening and flexibility exercises, pain management with NSAIDs, and activity modification to avoid symptom-triggering positions 1. For patients with osteoporosis contributing to deformity, bisphosphonates or other bone-strengthening medications should be considered. If conservative measures fail after 3-6 months, surgical intervention may be warranted, particularly for patients with progressive deformity, neurological deficits, significant pain, or functional limitations.
Key Considerations
- Surgical approaches typically involve decompression to relieve neural compression and spinal fusion with instrumentation to correct alignment and stabilize the spine.
- The specific surgical technique depends on deformity type, location, and severity, with options including posterior-only approaches or combined anterior-posterior procedures.
- Postoperative rehabilitation is crucial and should begin within 1-2 weeks after surgery.
- Total hip arthroplasty should be considered in patients with refractory pain or disability and radiographic evidence of structural damage, independent of age, and spinal corrective osteotomy may be considered in patients with severe disabling deformity 1.
Treatment Goals
- Relief of pain and stiffness
- Improvement of functional ability
- Prevention of disease progression
- Maintenance of quality of life
Individualized Treatment
- Treatment decisions should be based on a comprehensive assessment of the patient's condition, including disease severity, comorbidities, and functional goals.
- A multidisciplinary approach, involving orthopedic surgeons, physical medicine and rehabilitation specialists, and other healthcare professionals, may be necessary to develop an effective treatment plan.
- Patient education and shared decision-making are essential components of individualized treatment, allowing patients to make informed decisions about their care 1.
From the Research
Management of Adult Spinal Deformity
The management of adult spinal deformity (ASD) can be divided into non-operative and operative strategies.
- Non-operative management includes pain medications, physical modalities, exercises, bracing, or interventional procedures 2.
- Operative management, such as spinal fusion with instrumentation, is considered for severe disability and pain unresponsive to non-operative treatments 2, 3.
Non-Operative Management
Non-operative management strategies have shown beneficial outcomes in selected ASD patients with longstanding chronic low back pain (CLBP) 4.
- A combined physical and psychological programme (CPPP) can improve functional status, pain intensity, self-efficacy, and quality of life in ASD patients with CLBP 4.
- Exercise therapies, such as strengthening of back and abdominal muscles, neuromuscular re-education for daily tasks, and active self-correction, are vital to improve postural control and spinal stability 2.
- Bracing for a few hours a day can help reduce pain and provide spinal stability in adults 2.
Operative Management
Operative management is available and effective for ASD patients with disabling pain, functional impairment, or progressive spinal malalignment 3.
- Spinal fusion with instrumentation is a complex surgery associated with a significant risk of perioperative complications 3.
- Efficacy and safety are optimal when operative intervention is performed by a surgical team (and hospital system) experienced in the management of complex spinal pathology 3.
Rehabilitation
Postoperative rehabilitation can help reduce pain and disability and improve return to activity or work in ASD patients 2.
- Protecting the spine early after surgery and timing of initiation of exercises with respect to osseointegration and bone remodeling phases are important principles of postoperative rehabilitation 2.