Scoliosis and Adult Degenerative Curve

Adults with scoliosis are frequently told the curve is the problem and that nothing short of major surgery will change it. In most cases neither half of that is true.

Two different conditions share one name

Adolescent idiopathic scoliosis develops during growth, is usually painless, and is managed by observation, bracing or surgery depending on the curve. Adults who had it as teenagers often carry a stable curve for decades without symptoms.

Adult degenerative scoliosis is different. It develops later in life out of asymmetric disc and facet degeneration — the spine collapses unevenly and a curve forms as a consequence. This one usually does hurt, and the pain comes from the degeneration rather than from the curvature itself.

The practical consequence: knowing the Cobb angle tells you comparatively little about why someone is in pain.

Where the pain actually comes from

Inside a curve there are several distinct pain generators, and they are treatable individually even though the curve is not going anywhere:

• Facet joints on the concave side, which are compressed and loaded asymmetrically. See facet joint pain.
• Foraminal narrowing on the concavity, where the exit tunnels close down and compress a nerve root — producing leg pain that follows one specific root. See foraminal narrowing.
• The sacroiliac joints, loaded unevenly by a pelvis that is no longer level. See sacroiliac joint pain.
• Muscular fatigue on the convex side, where muscles work continuously against gravity to hold the trunk upright.
• Central canal stenosis, where degeneration has narrowed the canal as well as deforming it. See spinal stenosis.

Each of those produces a recognizable pattern, and each can be confirmed by targeted diagnostic injection. That is the entire basis of treating a painful curve without operating on it.

The symptom that matters most

Walking distance. Adults with degenerative scoliosis usually describe a distance beyond which the back and legs give out and they need to sit — the same neurogenic claudication seen in spinal stenosis, because the underlying mechanism overlaps.

Tracking that distance is more informative than tracking a pain score, and it is what treatment should be aimed at improving.

How it is treated here

• Diagnostic blocks to establish which structure is responsible, because a curve offers several candidates
• Medial branch blocks and radiofrequency ablation where the facet joints are confirmed
• Transforaminal epidural injection for a specific compressed nerve root on the concavity
• Sacroiliac joint injection where pelvic obliquity has loaded the joint
• Physical therapy aimed at endurance of the trunk muscles rather than at correcting the curve
• Surgical referral where there is progression, imbalance or neurological deficit

Does an adult curve get worse?

Degenerative curves do tend to progress slowly, typically by a small number of degrees per year, and progression is faster where there is significant rotation or a large curve to begin with. But progression on imaging and worsening symptoms are not the same thing, and many people remain functionally stable for years.

Monitoring is therefore worth doing and panic is not. What changes management is a change in function — walking distance, balance, new weakness — rather than a change in the angle.

To be assessed, call (314) 310-5577 or text (314) 886-5902. We are at 12174 Natural Bridge Road, St. Louis, MO 63044.

What usually gets missed

The commonest error in adult scoliosis is treating the curve rather than the pain. The magnitude of the curve correlates poorly with symptoms, and many substantial curves are entirely painless.

What usually generates the pain is secondary: facet joints on the concavity taking asymmetric load, foraminal narrowing on that side, and sacroiliac strain from a pelvis that is no longer level. Each of those is identifiable and treatable without addressing the curve at all.

What to expect over time

Adult degenerative curves progress slowly, typically a degree or two a year, and most do not reach a threshold where surgery is indicated.

Adolescent idiopathic curves and adult degenerative curves are genuinely different conditions with different natural histories, which is why advice given for one is frequently wrong for the other.