What is the optimal management strategy for scoliosis in adults older than 50 years?

Management of Scoliosis in Adults Over 50

For adults over 50 with scoliosis, initial management should focus on conservative treatment with NSAIDs, activity modification, and physical therapy for pain relief, reserving surgery for patients with curves exceeding 50 degrees, documented progression despite skeletal maturity, or refractory pain with neurological compromise. 1, 2

Initial Assessment and Risk Stratification

Clinical Evaluation

• Perform the Adams forward bend test combined with scoliometer measurement to assess curve severity, as this combination provides sensitivity of 84.37% and specificity of 93.44% 3
• Evaluate for shoulder height asymmetry during standing posture assessment 3
• Conduct a thorough neurological examination to assess for focal deficits, abnormal reflexes, muscle weakness, and pes cavus, as these findings may indicate underlying pathology requiring advanced imaging 3

Imaging Protocol

• Obtain standing PA and lateral radiographs of the complete spine to measure Cobb angle and assess curve type 3, 4
• MRI of the complete spine without contrast is mandatory before any surgical consideration to rule out neural axis abnormalities, particularly in patients with atypical features 4, 5
• Red flags requiring immediate MRI include left thoracic curve pattern, short segment curve, rapid progression (>1° per month), functionally disruptive pain, or focal neurological findings 3, 4

Conservative Management (First-Line Treatment)

Non-Surgical Approach

• Initiate NSAIDs and analgesics as the primary pharmacologic intervention for pain control 2
• Prescribe activity modification tailored to symptom severity 2
• Consider orthoses for symptomatic relief, though bracing is less effective in skeletally mature adults 2
• Implement physical therapy programs focused on flexibility and muscle balance, as improved flexibility correlates with pain reduction 6

Monitoring Protocol

• Obtain radiographs every 12-18 months to monitor for curve progression in symptomatic patients 4
• Thoracic curves exceeding 50 degrees may progress at approximately 1 degree per year even after skeletal maturity, necessitating ongoing surveillance 4, 5

Surgical Indications

Absolute Thresholds for Surgery

• Cobb angle exceeding 50 degrees in skeletally mature patients warrants surgical consideration due to continued progression risk 4, 5
• Documented curve progression despite skeletal maturity, particularly with associated pain or functional decline 4, 5
• Refractory pain unresponsive to at least 6 months of conservative treatment with evidence of spinal stenosis or nerve root compression 1, 7
• Progressive neurological deficit or spinal stenosis with radiculopathy 1

Pre-Operative Evaluation Requirements

• Obtain MRI of the entire spine before any surgical intervention, as neural axis abnormalities occur in more than 20% of severe cases and alter surgical planning 5
• Pulmonology evaluation to assess baseline lung function and screen for sleep hypoventilation with nocturnal oximetry or polysomnography 5
• Cardiology evaluation to assess for cardiomyopathy or arrhythmia risk under anesthesia 5
• Nutritional optimization to support healing and minimize complications 5

Surgical Approach

• Posterior spinal fusion with pedicle screw instrumentation is the standard approach, offering superior three-column purchase and correction power compared to hook constructs 4, 7
• Both allograft and autograft bone grafting are necessary to achieve solid arthrodesis 4, 5
• CT spine may be obtained for surgical planning to reduce screw misplacement from 15.3% to 6.5% 4

Post-Operative Management

Critical Post-Operative Care

• Implement aggressive airway clearance and respiratory support with pulmonologist follow-up 5
• If preoperative sleep studies showed hypoventilation, plan extubation to noninvasive ventilation 5
• Titrate pain management carefully to promote airway clearance while minimizing respiratory suppression 5

Special Considerations for Adults Over 50

Type-Specific Management

• Primary degenerative scoliosis (Type 1) is the most common presentation in this age group, characterized by asymmetric disc and facet joint arthritis with predominantly back pain and often accompanied by spinal stenosis 1
• Idiopathic curves progressing into adulthood (Type 2) may have secondary degeneration requiring more extensive fusion 1
• Osteoporosis-related curves (Type 3b) are particularly common in post-menopausal women and accelerate progression, requiring bone density optimization before surgery 1

Common Pitfalls to Avoid

• Do not assume normal neurological examination rules out intraspinal abnormalities—physical exam accuracy is only 62% for detecting such pathology 4
• Avoid overlooking neural axis abnormalities by skipping pre-operative MRI, as this occurs in over 20% of surgical candidates 5
• Do not delay surgical intervention in patients with progressive curves exceeding 50 degrees, as continued progression is inevitable at approximately 1 degree per year 4, 5

Expected Outcomes

• Significant back pain relief and patient satisfaction can be achieved and maintained long-term with surgical intervention in appropriately selected patients 7
• Pain improvement is a more reliable outcome in older patients compared to younger patients 7
• Restoration or improvement of coronal and sagittal balance is achievable in patients with preoperative imbalance 7