Degenerative scoliosis in the lumbosacral spine

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1 DOI: /chnriop ISSN X REVIEW Degenerative scoliosis in the lumbosacral spine Skolioza zwyrodnieniowa w części lędźwiowo-krzyżowej kręgosłupa Andrzej Nowakowski 1, Paweł Michalski 2, Mikołaj Dąbrowski 1 1 Department of Spondyloorthopedics and Biomechanics, Poznań University of Medical Sciences 2 Spinal Surgery and Orthopedics Ward, Institute of Mother and Child, Warsaw Abstract Degenerative scoliosis of the lumbosacral region occurs in 6% of the population over 50 years of age. It is often accompanied by low back pain resulting from fibular (in the majority of patients) or frontal decompensation. Radicular pain is common, radiating to one (more often) or both (less often) lower limbs and is most often caused by lateral stenosis. Key words: degenerative scoliosis, lumbosacral spine Streszczenie Skolioza zwyrodnieniowa zlokalizowana w części lędźwiowo-krzyżowej występuje u 6% populacji powyżej 50 roku życia. Towarzyszy jej często ból mechaniczny grzbietu (low back pain) wynikający z dekompensacji strzałkowej (u większości chorych) lub czołowej. Ból korzeniowy (radicular pain) występuje powszechnie, promieniując do jednej (częściej) lub obu (rzadziej) kończyn dolnych i wynika najczęściej ze stenozy bocznej. Słowa kluczowe: skolioza zwyrodnieniowa, kręgosłup lędźwiowo-krzyżowy Author s address: Andrzej Nowakowski, ul. 28 Czerwca 1956 nr 135, Poznań nowakowski@polishorthopaedics.pl Received: Accepted: Published:

2 REVIEW Epidemiology and classification The first group consists of patients with secondary degenerative changes of the intervertebral joints, previously diagnosed with idiopathic scoliosis as children and adolescents (juvenile and adolescent scoliosis) - preexistent scoliosis. The onset of changes takes place before the end of bone maturity and occurs more often in women. Scoliosis <30º usually does not progress, scoliosis >50º progresses, on average, at 1º to 2º per year. These changes may be accompanied by (co-occurring) spondylolysis, asymmetrical joint surfaces, oblique pelvic position, unequal length of the lower limbs, trauma and infection. The second group consists of patients with degenerative scoliosis which is not secondary to idiopathic scoliosis. In such a case we deal with primary degenerative scoliosis (de novo scoliosis). It begins once the bone maturity ends, it is more common in men, with an average progression of 3º per year, and rarely exceeds 40º of Cobb angle. Degenerative changes affect the intervertebral disc, intervertebral joints and lateral displacement of the vertebrae (lateral translation olisthesis) [1,2]. Pathomechanism Primary degenerative scoliosis de novo scoliosis (Fig. 1) [3,4,5]. Clinical symptoms are strictly connected with pathomorphology (Fig. 2). Risk factors for degenerative scoliosis progression are presented in figure 3 [6,7,8]. Fig. 1. Strict interrelation between asymmetric loading, segmental degenerative changes (disc, joint surfaces) and deformation (vicious circle) - after Max Aebi Fig. 2. Progressive degeneration and deformation lead to central, lateral and recessal stenosis after Max Aebi. 114

3 REVIEW and nerve structures, CT + myelography are currently used less frequently (but it provides a precise assessment of the location, radicular compression - 3D assessment is important in their correlation with clinical symptoms). Paravertebral injections are sometimes helpful in identifying trigger points for pain. Also available are provocative discography, articular surface blocks, nerve root blocks and epidural blocks [4,5,10]. Non-operative treatment The overall goal of the treatment is to relieve the patient s pain, neurogenic claudication, to reverse the neurological deficit and prevent the progression of curvature. Possible therapeutic options are presented in Table 1 [1,13]. Table 1. Possible therapeutic options. Fig. 3. Cobb angle > 30º, lateral listhesis 6mm, vertebral rotation IIº, the line connecting iliac crests runs through or below L4/L5. Back pain Clinical assessment Radicular pain, neurological deficit The study should take into account four main causes and related symptoms: low back pain - often due to segmental instability (axial back pain), symptoms of claudication or radicular pain (central, lateral and recessal stenosis) [9,10]. The patient complains of a long history of pain gradually increasing before the occurrence of neurogenic claudication (psudoclaudicatio, claudicatio neurogenes) [9, 11]. In these patients, a neurological deficit is rare. Large curvatures progress faster than small ones due to biomechanical factors (passive collapse of curvatures 1º to 3º per year) [1,2,3,12,13]. Clinical data The data should include examination of patients in a standing position and the assessment should concern: oblique pelvis position, presence of gibbus deformity or lumbar elevation, shoulder girdle, asymmetry of waist triangles, flat back, sagittal and frontal decompensation [6,11,14]. Imaging studies Imaging studies should include conventional radiographs obtained in both planes, both oblique projections (45º), sometimes x-ray are taken to evaluate the curvature correction. MRI examination for the assessment of adjacent soft tissues Spinal claudication Curvature progression NSAIDs Corset Joint injection Isometric exercises Swimming NSAIDs Isometric exercises Orthesis Nerve root blocks Surgical decompression Epidural blocks NSAIDs Isometric exercises Surgical decompression Corset Surgical stabilization (instrumentarium spondylodesis) Surgical treatment The decision to introduce surgical treatment is often complex and depends on many factors: It is generally reserved for patients with persistent radicular pain (pain in the limb not relieved by non-operative therapy). The choice of technique depends on age, main symptoms, sagittal and frontal compensation, stiffness, secondary curvature correction. The surgical correction is recommended in patients with severe pain and significant spinal decompensation in both planes (especially in the sagittal plane). It should be clearly stressed that the need for surgical correction of degenerative curvature decreases with age. Surgical treatment is rarely warranted (it concerns 1 to 3% of patients), but may be the right choice in progressive curvatures and severe spinal sagittal decompensation. The use of segmented back fixation with transpedicular screws and posterolateral spondylodesis is currently the standard of surgical management: Serious hard curvatures in young adults require combined posterior and anterior 115

4 REVIEW approach if the anterior-posterior release is not sufficient. Wedge osteotomy and curvature correction with transpedicular screws may be necessary to restore spinal compensation. In some cases, the indication may be the use of segmental correction using ALIF (anterior lumbar interbody fusion) and PLIF (posterior lumbar interbody fusion). Fixation to the sacral bone should be avoided, but if it proves necessary, interbody fusion of L5/S1 is obligatory (prevention against non-union) [9,11,15-20]. Treatment algorithm for degenerative scoliosis with low back pain is presented in Fig. 4. Low back pain with neurogenic claudication /radiculopathy (Fig. 5). Fig. 4. Treatment algorithm for degenerative scoliosis with low back pain Fig. 5. Low back pain with neurogenic claudication /radiculopathy 116

5 REVIEW Fig. 6. F 56 y.o. Lumbar degenerative scoliosis, central and lateral stenosis, decompression of L4-S1 posterolateral fixation, segmental correction of the curvature with the restoration of lumbar lordosis. Fig. 7. F. 59 y.o. Slight degenerative lumbar scoliosis, radiculopathy, L5/S1 decompression, segmental L4-S1 stabilization spondylodesis, restoration of lumbar lordosis. Fig. 8. F. 62 y.o. Degenerative lumbar scoliosis Cobb angle 48º, central, lateral and recessal stenosis, L4/L5 decompression, transpendicular correction and stabilization of T11/S1 (instr. AESCULAP) lumbar kyphosis (- 32º > +10º) restoration of lumbar lordosis. 117

6 REVIEW Summary In the majority of patients with degenerative scoliosis in the lumbosacral region slight deformities are diagnosed which do not exceed 30º of Cobb angle. About 95% of them do not require surgical intervention. Only 1 to 4% needs to be treated surgically (progressive curvature, persistent chronic low back pain with symptoms of radiculopathy and neurological deficit.) Today, the currently applied method of correction and stabilization of the spine in carefully selected patients is a multi-segmented instrumentation using transpendicular screws and posterior spondylodesis. References 1. Aebi M.: The adult scoliosis. Eur.Spine J.;2005;14(10); Boachie-Adjei O.: Adult scoliosis + Deformity. AAOS Instructional Course Lectures:1999;48(39); Benner B., Ehni G.: Degenerative lumbar scoliosis. Spine:1979;4: Grubbo S.A.,Lipscomb H.J.,Coonrad R.W.: Degenerative adult onset scoliosis. Spine 1988;13: Grubbo S.A.,Lipscomb H.J.: Diagnostic findings in painful adult scoliosis.spine 1992:17(5); Ascani E.,Bartolozzi P., Logroscino C.A., Marchetti P.G., Ponte A., Savini R., Travaglini F., Binazzi R., Di Silvestre M.: Natural history of untreated idiopathic scoliosis after skeletal maturity. Spine 1986:11(8); Ponseti I.V.: The pathogenesis of adult scoliosis. ZorabPA (eds) Proceedings of second symposium on scoliosis causation.e&livingstone. 8. Nowakowski A.: Ortopedia i traumatologia. Podręcznik dla studentów medycyny. Exemplum, Poznań Tribus C.B.: Degenerative lumbar scoliosis evaluation and management. J.Am. Acad. Orthop. Surg.;2003:11(3): Winter R.B., Lonstein J.E., Denis F.: Pain patterns in adult scoliosis. Orthop. Clin.North.Am. 1988:19: Kostuik J.P.: Recent advances in the treatment of painful adult scoliosis. Clin. Orthop.:1980;147: Grubbo S.A.,Lipscomb H.J., Suh P.B.: Result of surgical treatment of painful adult scoliosis. Spine;1994:19: Ogilvie J.W.:Adult scoliosis evaluation and nonsurgical treatment. Instructional course lectures.1992:41: Deviren V., Berven S.,Kleinstueck F., Antinnes J., Smith J.A., Hu S.S.: Predictors of flexibility and pain patterns in thoracolumbar and lumbar idiopathic scoliosis. Spine;2002:27(21): Aebi M.: Correction of degenerative scoliosis of the lumbar spine. A preminary report Clin. Orthop.Related Res.:1988;232: Ali R.M., Boachie-Adjei O.,Rawlins B.A.:Functional and radiographic outcomes after surgery for adult scoliosis using third-generation instrumentation tehniques. Spine;2003:28(11): Takahashi S., Dele crin J.,Passuti N.: Surgical treatment of idiopathic scoliosis in adults. An age-related analysis of outcome. Spine 2002:27(16): Marchesi D.G., Aebi M.: Pedicle fixation devices in the treatment of adult lumbar scoliosis. Spine:1992:17: Simmons E.D.,Kowalski J.M., Simmons E.H.: The resultsof surgical treatment for adult scoliosis. Spine 1993:18: Johnson J.R., Holt R.T.: Combined use of anterior and posterior surgery for adult scoliosis. Orthop. Clinic. Nort.Am.1988:19: