What are the treatment options for an adult patient with scoliosis?

Adult Scoliosis Treatment

For adult scoliosis, treatment should be stratified by curve severity and symptoms: curves <15° require annual clinical monitoring with Adam's forward bend test; curves 15-50° benefit from physical therapy with scoliosis-specific exercises and closer radiographic surveillance; and curves >50° in skeletally mature adults warrant surgical evaluation due to continued progression at approximately 1° per year. 1, 2

Initial Assessment and Classification

Adult scoliosis encompasses four distinct types that guide treatment decisions 3:

• Type 1 (Primary degenerative): De novo scoliosis from asymmetric disc/facet arthritis, often with spinal stenosis 3
• Type 2: Adolescent idiopathic scoliosis progressing into adulthood with secondary degeneration 3
• Type 3: Secondary curves from pelvic obliquity, metabolic bone disease, or osteoporotic fractures 3

Initial evaluation requires PA and lateral spine radiographs to diagnose, classify severity, and assess progression risk 2. The pathomechanism involves asymmetric degeneration leading to increased asymmetric load, creating a vicious cycle of progressive deformity, particularly in postmenopausal women with osteoporosis 3.

Treatment Algorithm by Curve Severity

Curves <15° (Mild Scoliosis)

• Annual clinical evaluation using Adam's forward bend test 4, 2
• Radiographic monitoring every 12-18 months for stable curves 2
• Refer to orthopedics if progression is detected 4, 2

Curves 15-20° (Moderate Mild Scoliosis)

• Physical therapy focusing on core strengthening and postural awareness to manage symptoms 2
• More frequent monitoring (every 6 months) to detect potential progression 2
• Physiotherapy Scoliosis-Specific Exercises (PSSE) incorporating 3-dimensional self-correction, training in activities of daily living, and stabilization of corrected posture 5

Curves 20-50° (Moderate to Severe)

• Continue PSSE as these exercises can temporarily stabilize progressive curves and produce temporary Cobb angle reduction in non-progressive scoliosis 5
• Consider bracing in select cases, though evidence in adults is limited 6
• Intensified monitoring for progression 2

Curves >50° (Severe Scoliosis)

• Surgical evaluation is warranted due to risk of continued progression at approximately 1° per year in skeletally mature adults 1, 2
• Surgical management may include decompression, correction, stabilization, and fusion procedures or combinations thereof, tailored to specific symptomatology 3
• Surgery should be performed by orthopedic surgeons highly experienced in adult scoliosis 1

Symptom-Specific Management

Adult scoliosis patients present predominantly with back pain, then leg pain and claudication, rarely with neurological deficit 3:

• For back pain: PSSE can improve secondary muscle imbalance and related pain through 3D self-correction and stabilization 5
• For spinal stenosis symptoms: Diagnostic evaluation including myelo-CT, discograms, facet blocks, and epidural blocks to guide least invasive treatment 3
• For severe thoracic curves: PSSE can improve breathing function 5

Red Flags Requiring Aggressive Management

• New neurological symptoms 2
• Rapid curve progression despite skeletal maturity 2
• Pain unresponsive to conservative measures 2

Special Considerations and Contraindications

• Avoid spinal manipulation with high-velocity thrusts in patients with spinal fusion or advanced spinal osteoporosis due to risk of spine fractures, spinal cord injury, and paraplegia 4
• Female patients have higher progression risk (female-to-male ratio of 10:1 for larger curves) 2
• Osteoporosis management: Earlier screening with DXA may be warranted; bisphosphonate therapy should follow general population guidelines with NF1 entered as risk factor in fracture assessment tools 4

Common Pitfalls to Avoid

• Do not assume no progression due to absence of symptoms - curves can progress silently 2
• Do not delay evaluation of new or worsening symptoms 2
• Avoid overtreatment - surgical intervention is not indicated for mild scoliosis 2
• Avoid excessive radiation exposure by following recommended monitoring intervals 2
• Do not substitute unsupervised exercises for initial instruction by a physical therapist 4

Multidisciplinary Approach

Treatment requires coordination between orthopedic spine surgeons, physical therapists, and when indicated, mental health providers 5. For complex cases with concurrent pathology, coordination with appropriate specialists is necessary to determine if simultaneous interventions are appropriate 1.