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

Treatment Options for Elderly Patients with Scoliosis

For elderly patients with scoliosis, treatment should begin with conservative management including physical therapy, core strengthening, and pain control, reserving surgery for curves exceeding 50 degrees, documented progression, intractable pain unresponsive to conservative measures, or new neurological symptoms. 1, 2

Initial Conservative Management

Conservative treatment forms the foundation of management for most elderly patients with scoliosis:

• Physical therapy focusing on core strengthening and postural awareness helps manage symptoms and maintain spinal stability 1, 3
• Postural awareness training should teach patients to maintain proper alignment during daily activities and avoid leaning on one side, which can exacerbate scoliosis 1, 3
• Pain management strategies include regular stretching exercises, non-steroidal anti-inflammatory medications, and physical modalities such as heat or massage 1, 3
• Core strengthening may prevent further deterioration by maintaining better spinal alignment and reducing compensatory stress 4, 3

Monitoring and Surveillance

Regular monitoring is essential even in skeletally mature elderly patients:

• Radiographic surveillance every 12-18 months is recommended to track potential curve progression 1, 3
• Thoracic curves greater than 50 degrees may continue to progress at approximately 1 degree per year even in adults, requiring more vigilant monitoring 3
• Clinical evaluation should include annual assessment with Adam's forward bend test to monitor for curve progression 1
• Avoid excessive radiation exposure by adhering to recommended monitoring intervals rather than ordering more frequent radiographs 1, 3

Surgical Indications

Surgery should be considered when specific criteria are met:

• Curves exceeding 50 degrees warrant surgical consideration due to risk of continued progression 1, 4, 2
• Documented curve progression despite skeletal maturity 1, 3
• Significant pain not responding to conservative measures after adequate trial of physical therapy and medications 1, 3, 5
• New neurological symptoms including weakness, numbness, or bowel/bladder dysfunction 1, 3
• Significant cosmetic concerns affecting quality of life 1
• Spinal stenosis symptoms with claudication or radicular pain 2, 6

Surgical Approach Considerations

When surgery is indicated, the approach must be tailored to the individual patient's pathology:

• Surgical options include decompression alone, instrumented posterior spinal fusion, anterior spinal fusion, osteotomy, or combinations of these procedures 2, 5, 6
• The main goals are symptom relief, correction of deformity in coronal and sagittal planes, and achievement of solid fusion 5
• Fusions ending at L4 or L5 show greater improvements in some functional outcomes compared to fusions involving the sacrum 7
• Minimal invasive procedures may become increasingly important in older patients to address the most relevant clinical problem while minimizing surgical morbidity 2

Expected Outcomes and Complications

Elderly patients should be counseled about realistic expectations:

• Complication rates are high (approximately 49% overall, with 26% major complications) in patients aged 40 years or older undergoing scoliosis surgery 7
• Despite high complication rates, statistically significant improvements occur in disability scores, quality of life measures, and functional outcomes 5, 7
• The morbidity is comparable to other established orthopedic procedures like hip replacement in the same age group 2
• Successful clinical outcomes appear to outweigh the high potential complication rates in appropriately selected patients 6, 7

Critical Red Flags Requiring Immediate Evaluation

The following warrant urgent assessment:

• New neurological symptoms including weakness, numbness, or bowel/bladder dysfunction 1, 3
• Rapid curve progression 1, 3
• Functionally disruptive pain 1
• Focal neurological findings on examination 1, 3

Common Pitfalls to Avoid

• Do not assume no progression due to absence of symptoms in skeletally mature patients, as curves can continue to progress 3
• Do not delay evaluation of new or worsening symptoms 3
• Do not order radiographs more frequently than recommended monitoring intervals to avoid excessive radiation exposure 1, 3
• Do not abandon regular monitoring even in skeletally mature elderly patients 1