Author(s): Melissa Mafiah, MD, Sean Sellwood, MD, James Borges, MD
Originally published: November 14, 2011 Last updated: April 24, 2025
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Disease/Disorder

Definition

Adult Degenerative Scoliosis (ADS) is defined as a lateral curvature of the spine in the coronal plane that develops after skeletal maturity in a previously normal spine.1 ADS is primarily driven by degenerative changes associated with spinal spondylosis. This de novo deformity typically develops after age 50 or represents the progression of a previously mild, unrecognized scoliosis that worsens due to age-related degeneration of the intervertebral discs and facet joints, leading to progressive spinal asymmetry, vertebral rotation, and segmental instability. It is defined by a Cobb angle of ≥10º measured using anteroposterior (AP) or lateral standing radiographs of the spine. First, identify the upper and lower-end vertebrae of the scoliotic curve. Draw a line along the superior endplate of the upper-end vertebra and the inferior endplate of the lower-end vertebra. Perpendicular lines are drawn from these reference lines, and the angle formed at their intersection represents the Cobb angle.1,2 In ADS, curve progression and rotational deformity may complicate the accurate measurement, necessitating follow-up imaging and clinical correlation.3 ADS most frequently develops in the lumbar spine. In contrast, involvement of the thoracic spine is commonly associated with idiopathic scoliosis, and the thoracolumbar and lumbar spine are affected most in neuromuscular scoliosis.

Etiology

ADS is a progressive spinal deformity that occurs due to age-related degenerative changes in the spine. It can be a sequela of the progression of idiopathic adolescent scoliosis as well as the asymmetric degeneration of spinal motion segments, defined as two adjacent vertebral bodies, the intervertebral disc, facet joints, and interconnecting ligaments that lead to coronal and sagittal plane deformities.4 The primary diseases that lead to ADS can allow for the subcategorization into three major classifications. Type I ADS, or primary degenerative scoliosis, results from asymmetric degeneration of the intervertebral discs and facet joints and arises in patients with no prior history of scoliosis. The condition typically results from age-related degenerative changes such as spinal stenosis, spondylolisthesis, rotational or lateral subluxation, and ligamentum flavum hypertrophy.5 This results in a cycle of asymmetric loading of the spine causing segmental instability and further degeneration and spine deformity.6,7 Type II ADS, or secondary degenerative scoliosis, refers to the progression of pre-existing untreated or minimally treated adolescent idiopathic scoliosis (AIS) into adulthood, with superimposed degenerative changes exacerbating spinal curvature and symptoms.8 Type III ADS is characterized by severe sagittal malalignment due to progressive disc degeneration, vertebral body collapse, and sagittal plane deformities. This subtype is closely linked to adult spinal deformity from prior spinal surgery, trauma, osteoporosis, or osteoarthritis and results in significant postural dysfunction.6,7,9

Epidemiology including risk factors and primary prevention

Adult Degenerative Scoliosis (ADS) is primarily a disease of aging populations, with most cases diagnosed in individuals over the age of 50. Studies have shown that the prevalence of ADS increases significantly with age, affecting approximately 30% of adults over 50 and up to 68% of those over 60.10,11 Women are disproportionately affected by ADS, with a female-to-male ratio ranging from 1.5:1 to 3:1. This disparity could largely be attributed to postmenopausal osteoporosis, which accelerates vertebral body degeneration and ligamentous laxity, increasing the likelihood of curve progression.2 The severity of ADS is commonly classified by Cobb angle measurements as 47–60% of cases classified as mild (10°–20° Cobb angle), 30–40% as moderate (21°–40°), and 10–15% as severe (>40°).12,13 Curves typically progress 3º-4° per year, with faster progression in those with osteoporosis, degenerative disc disease, or pre-existing instability. Larger curves (>30°) and those with sagittal imbalance are more likely to become symptomatic and require intervention. Risk factors for ADS include aging, female sex, osteoporosis, obesity, and degenerative spinal changes. Aging leads to progressive intervertebral disc degeneration, facet joint arthritis, and ligamentous laxity, contributing to spinal instability and curve progression.14 Women are at higher risk, likely due to postmenopausal osteoporosis and hormonal influences on bone metabolism.15 Osteoporosis accelerates vertebral body collapse and deformity, worsening spinal alignment and increasing curve progression.16 Obesity adds mechanical stress, exacerbating vertebral degeneration, sagittal imbalance, and pain severity.17 Additional risk factors include a history of lumbar spine surgery which may lead to adjacent segment degeneration, and a sedentary lifestyle, which contributes to muscle deconditioning and loss of spinal support.18

Key strategies for ADS prevention include maintaining optimal bone health through calcium and vitamin D intake, which has been shown to reduce the risk of osteoporosis-related vertebral deformities.19 Regular weight-bearing and core-strengthening exercises help improve spinal stability, reduce mechanical stress, and minimize degenerative changes. Additionally, maintaining a healthy body weight is also critical, as obesity increases the mechanical load on the spine and accelerates disc degeneration, leading to structural instability.20 Lifestyle modifications such as smoking cessation and limiting excessive alcohol consumption are critical as both have been linked to accelerated disc degeneration and poor bone quality.21 Management of metabolic disorders such as diabetes and obesity can reduce systemic inflammation, which contributes to intervertebral disc degeneration and musculoskeletal deterioration.22 While ADS cannot always be prevented, these proactive strategies can help delay disease onset and progression, improving long-term spinal health and function.

Patho-anatomy/physiology

Adult degenerative scoliosis refers to a structural curve that begins after skeletal maturity. The most important concept to appreciate in understanding the pathophysiology of ADS spinal instability is the spine asymmetry caused by disc and facet joint degeneration.7 The pathogenesis of ADS begins with age-related asymmetric degeneration of the intervertebral discs with structural change to disc anatomy (decreasing disc height, decreased proteoglycan and water content of discs, and increasing enzymatic degradation). This process leads to asymmetrical disc space collapse and subsequent facet degeneration at multi-segmental levels. This leads to osteophyte formation of the facet and vertebral end plate, subchondral sclerosis, and subchondral cyst formation. Further abnormalities include ligamentous laxity with a decline in surrounding musculature, and ligamentum flavum hypertrophy that ultimately results in spinal instability and development of the scoliotic curve.

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

The natural history of ADS follows a predictable trajectory of gradual structural deterioration, worsening sagittal and coronal imbalance, increasing pain, and functional decline over time. The disease progresses through distinct phases beginning with early degenerative changes, followed by curve progression, and ultimately leading to severe spinal deformity with functional impairment.14,23 Early degeneration, characterized by intervertebral disc degeneration, facet joint arthritis, and ligamentous laxity, often presents with mild axial back pain.23 Pain at the convexity of the curve is caused by fatigue of the paraspinal muscles or from facet joints. Pain at the concavity of the curve is due to the destruction of facet joints and degeneration of intervertebral discs.7,24,25,26 As the disease advances, the scoliotic curve begins to progress at a rate of approximately 3°–4° per year, leading to segmental instability, lateral listhesis, and foraminal or central stenosis, resulting in mechanical back pain, radiculopathy, and neurogenic claudication.27 During this stage, patients often develop compensatory postural adaptations, including pelvic obliquity and thoracic hyperkyphosis, which further exacerbate pain and mobility limitations. In the advanced phase, deformities exceeding a 40° Cobb angle can cause fixed kyphoscoliosis, disabling pain, postural imbalance, gait abnormalities, and even restrictive pulmonary dysfunction, significantly impairing quality of life.28,29 Severe stenosis and foraminal narrowing may result in neurological deficits, including weakness, sensory loss, and bowel/bladder dysfunction in extreme cases.30

Specific secondary or associated conditions and complications

ADS is frequently associated with a range of secondary conditions and complications that can impact patient outcomes. Chronic back pain is one of the most common symptoms of ADS. The imbalance of mechanical forces leads to progressive axial and radicular pain. Studies show that pain severity often correlates with sagittal plane deformity, as increased forward displacement of the trunk places excessive strain on the spine and lower extremities.31 Progressive degeneration in ADS often results in spinal canal and foraminal stenosis. Patients may develop neurogenic claudication, with symptoms of leg pain, numbness, and weakness that worsen with standing and ambulation but improve with sitting or lumbar flexion. Additionally, foraminal narrowing may lead to radiculopathy, characterized by dermatomal pain, sensory deficits, and motor weakness. In severe cases, thoracolumbar myelopathy can occur due to direct spinal cord compression, leading to gait instability, hyperreflexia, and bowel/bladder dysfunction.7 Sagittal malalignment, specifically positive sagittal balance, is a key predictor of disability in ADS.32 Patients with an increased sagittal vertical axis (SVA) > 5 cm experience greater difficulty with posture and ambulation.14,33 Postmenopausal women are at increased risk of osteoporosis and associated fractures. Vertebral compression fractures exacerbate spinal deformity by further increasing kyphosis. In severe cases of ADS with large thoracolumbar curves (>50°), respiratory and cardiovascular complications may arise. Restrictive lung disease can develop due to thoracic cage compression, leading to reduced pulmonary function and exercise intolerance.34 Cardiovascular strain may also increase, contributing to hypertension and reduced cardiac output in elderly patients.35 Lastly, psychosocial distress is common in ADS, with studies demonstrating a higher prevalence of depression and anxiety.36 Chronic pain, progressive disability, and body image concerns contribute to lower self-esteem, social withdrawal, and decreased overall quality of life.37

Essentials of Assessment

History

Evaluation should include the following elements

  • Initial onset, location, duration, characteristics, and modalities of treatment to determine if consistent with ADS
  • Visible deformity does not fully reflect the extent of the disease, as scoliosis may continue to progress despite the presence of an observable curve.
  • Question any changes in body habitus, gait pattern, or improper fitting of clothes suggests a clinically significant progression.41
  • Question the pain the patient has and determine if it is purely axial or also radicular. The most common presenting symptom of ADS is axial back pain that improves with rest.7 According to Lenke et al. axial backache of a tolerable nature, not relieved leaning forward, is typically the result of sagittal imbalance whereas an increase in the severity of the axial pain to an intolerable level that is relieved by leaning forward usually indicates the cause of the axial pain to be spinal stenosis and neurogenic claudication.41
  • Radicular pain is a second important symptom of ADS and requires assessing whether its location aligns with concavity or convexity. Nerve roots are stretched along the convexity and compressed due to foraminal narrowing in the concavity.38 Identifying if leg pain arises from central, lateral recess stenosis, or both is crucial, as combined stenosis may require more extensive decompression and fusion.14
  • It is important to note that pain does not directly correlate to the size of the curvature, however, rotational subluxation and sagittal imbalance may exacerbate the pain.39
  • Nighttime pain or persistent discomfort may indicate an underlying condition like spondylolisthesis, Scheuermann kyphosis, syringomyelia, tethered cord, or an intraspinal tumor. It’s important to distinguish mild, fatigue-related pain from severe, pathologic pain that warrants further evaluation with MRI or bone scans.
  • The rapid development of a severe curve suggests a non-idiopathic type of scoliosis.
  • Weakness, sensory changes, bowel or bladder control changes, and other neurologic symptoms.40

Physical examination

Visual Inspection

  • Patients should be examined with their backs exposed and stand with hips and knees fully extended to observe for waist and/or rib asymmetry, pelvic obliquity, shoulder asymmetry, and overall spinal alignment.39
  • Observe any skin markings (café-au-lait spots, hyper- or hypopigmentation, signs of neurofibromatosis, dysraphic signs, etc.)
  • Leg length discrepancy and hip and/or knee flexion contractures should be assessed. When present, a shoe lift should be inserted on the shorter side to determine whether or not the curve is correctable.
  • Adams forward-bend test assesses rib and paraspinal deviation. It is evaluated by having the patient bend forward at the waist with their knees straight. Any asymmetry should be noted as upper thoracic, midthoracic, thoracolumbar, and lumbar.

Exam

  • Range of motion, joint deformity, joint laxity, etc.
  • Excess laxity of the joints and/or skin may be related to a syndrome such as Ehlers-Danlos or Marfan.40
  • Forward (Adam’s test) and lateral bending maneuvers help assess the curve’s rigidity, which is an important factor in terms of prognosis. Leg-length discrepancy and pelvic obliquity are also evaluated.41
  • A neurological examination, including all cranial nerves, motor strength, reflexes, sensory modalities, and gait, is performed.41
  • Sacroiliac joints and trochanters are palpated and evaluated for any hip or knee contractures, and the degree of flexibility is noted.41

Functional assessment

Activities of daily living (ADL) and Functional Independence Measure (FIM) scores can help assess function (self-care, sitting balance, breathing, feeding, transfers, mobility, ambulation, bowel and bladder management, etc.). Cognition is unaffected by scoliosis, and the presence of change in cognition suggests alternate etiologies.

Laboratory studies

Laboratory studies are unnecessary except when used to determine if a patient is a suitable operative candidate.

Imaging

  • Obtain full-length standing anteroposterior and lateral spine X-rays with Cobb angle measurement.
  • Supine long cassette radiographs may be considered as they eliminate gravity and will quickly show the degree of spontaneous correction. These are useful if surgical intervention is planned.39
  • Routine MRI is not indicated as part of the diagnosis. MRI may be later indicated before treatment such as injections or surgery.

Supplemental assessment tools

ADS patients with severe spinal curves should have pulmonary function tests (PFT) due to the potential for restrictive lung disease. Moderate curves can benefit from baseline PFTs due to the risk of pulmonary compromise with the progression of the disease.

Early predictions of outcomes

Some studies have shown that only approximately 15% of ADS patients are reported to be symptomatic, with most cases reporting only mild to moderate symptoms.42 However when symptomatic, the 2017 study by Passias and colleagues stated that few conservative treatments succeed in halting or slowing the progression. The necessity for surgery is determined by symptomatic progression and functional decline rather than radiographic severity. Given the aging population and the improvement of modern surgical approaches, the rates of ADS surgery have increased.43 It was found that patient satisfaction and clinical outcomes were rated higher with surgical intervention for symptomatic cases.43 Poor prognostic indicators for surgery included male sex and pre-existing depression.43

Social role and social support system

Adult degenerative scoliosis (ADS) not only imposes physical limitations but also significantly affects mental health and psychosocial well-being. Studies have demonstrated a strong correlation between spinal deformities and mood disorders, including depression and anxiety.10 ADS patients commonly report poor body image, reduced self-esteem, and social withdrawal due to their altered posture, chronic pain, and functional decline.

Patients with ADS experience higher rates of depression and anxiety compared to the general population. Research has shown that individuals with greater spinal curvature and associated pain often report poorer mental health outcomes. A study by Schwab et al. found that patients with severe spinal deformities reported significantly higher scores on the Patient Health Questionnaire-9 (PHQ-9), indicating greater depressive symptoms.32 Furthermore, ADS patients with greater limitations in activities of daily living (ADLs) are more prone to psychological distress, which can worsen pain perception and impede rehabilitation efforts.45 The altered body posture, reduced mobility, and chronic pain associated with ADS can negatively impact self-image and confidence. Poor body image and social anxiety may further isolate these patients, contributing to emotional distress and diminished social participation.38 Functional limitations, including difficulty dressing, bathing, or ambulating, are common in ADS and can significantly reduce independence. Loss of autonomy has been linked to increased rates of depression and anxiety in this population.45

Comprehensive care for ADS patients should include mental health support to address these challenges. Psychiatrists, psychologists, and social workers play a vital role in providing counseling, cognitive-behavioral therapy (CBT), and coping strategies. Group therapy programs and community-based support groups can also reduce feelings of isolation and improve overall well-being.46 Addressing mental health concerns and fostering strong social support networks are crucial in managing ADS. A multidisciplinary approach that integrates mental health professionals, social services, and family support can improve emotional resilience, enhance coping mechanisms, and ultimately optimize functional recovery and quality of life.

Rehabilitation Management and Treatments

Available or current treatment guidelines

Non-Operative Treatment

Non-operative management is the primary treatment approach for many patients with adult degenerative scoliosis (ADS), particularly those with mild to moderate curvature, minimal neurological deficits, or significant surgical risks.

Exercise-based therapies, including core strengthening, stretching, and postural correction, are fundamental in managing ADS. Studies have demonstrated that targeted physical therapy programs can improve pain, balance, and overall function in patients with ADS.47 Core stabilization exercises are particularly effective in improving spinal alignment, reducing mechanical pain, and enhancing muscular endurance.48 Low-impact aerobic exercises such as swimming, walking, and cycling help maintain mobility without excessive spinal strain.49 Studies have shown that supervised exercise therapy is associated with reduced disability and improved quality of life in ADS patients.50

Excess body weight contributes to increased mechanical load on the spine, exacerbating pain and accelerating degenerative changes.51 Weight loss through dietary modifications and structured physical activity can reduce stress on the lumbar spine, decreasing symptom severity and functional limitations.51 A study by Shiri et al. (2015) found that obesity is an independent risk factor for lumbar degenerative conditions, highlighting the importance of weight management in ADS treatment.52

Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are first-line agents for pain control. Muscle relaxants may provide short-term relief for muscle spasms, while neuropathic agents (e.g., gabapentin, pregabalin) are effective for radicular symptoms.49,53 For patients with severe pain or functional limitations, epidural steroid injections and facet joint blocks may offer temporary relief, especially in those with concurrent spinal stenosis.50 Patient selection for injection therapy is based on symptomatology, imaging findings, and clinical examination. Candidates include those with significant pain affecting function but without progressive neurological deficits or structural instability requiring surgery. Indications include axial back pain from facet arthropathy, radicular pain due to foraminal stenosis, and neurogenic claudication from central stenosis.49 Epidural steroid injections (ESIs) are beneficial in patients with nerve root compression and radicular symptoms, particularly when surgical intervention is not immediately feasible.54 Facet joint injections are indicated for patients with mechanical back pain suspected to originate from degenerative facet arthropathy, confirmed by diagnostic blocks.55 Rosen et al. demonstrated that 66% of patients with ADS had pain relief at 2 months and 25% at 8 months following an interlaminar ESI.56 Nam and Park showed that patients with degenerative lumbar scoliosis combined with spinal stenosis achieved effective pain relief for three months after transforaminal steroid injections (TFESI) for radicular pain.57 Radiofrequency ablation (RFA) is indicated in patients with confirmed facet-mediated pain who experience significant but temporary relief from diagnostic medial branch blocks.58 RFA has demonstrated efficacy in reducing facet joint pain, with benefits lasting 6-12 months.59 While RFA does not contribute to scoliosis progression, there is concern that pain relief may encourage increased activity without adequate spinal stabilization, potentially exacerbating mechanical strain.60 While these interventions provide symptomatic relief, they should be combined with rehabilitation and postural stabilization strategies to prevent further functional decline.

Alternative approaches such as acupuncture, massage therapy, and cognitive behavioral therapy (CBT) have been explored for pain relief in ADS. Acupuncture and massage may provide short-term analgesic benefits, while CBT can help address pain-related distress and improve coping strategies.61 Although bracing has not been shown to correct spinal deformities in adults, it can provide symptomatic relief by improving trunk stability and posture. There is evidence to suggest that spinal brace/orthosis treatment may have a positive short – medium-term influence on pain and function in adults with either progressive primary (de novo) degenerative scoliosis or progressive idiopathic scoliosis.62 Research shows that customized braces can reduce pain and improve function in selected ADS patients, particularly those with sagittal imbalance or postural decompensation.63

Osteoporosis management is a critical component of treating ADS, as low bone mineral density is strongly associated with curve progression, vertebral fractures, and poorer outcomes following both conservative and surgical interventions.64 Patients with osteoporosis have an increased likelihood of vertebral fractures, which can lead to worsening sagittal imbalance, increased kyphosis, and further deterioration of spinal alignment.65 Studies suggest that patients with lower BMD experience more rapid degenerative changes, leading to greater disability and reduced efficacy of conservative treatments such as bracing and physical therapy.64 First-line pharmacologic management in ADS includes bisphosphonates, which have been shown to reduce vertebral fracture rates and preserve spinal alignment. Denosumab is another effective option, particularly for patients at high fracture risk, as it has been demonstrated to increase BMD and reduce spinal fractures.66 Adequate calcium and vitamin D intake is essential for optimizing bone health, as deficiencies in these nutrients are linked to increased fracture risk and spinal deformity progression.66

Patients with ADS undergoing conservative management should be monitored for disease progression, particularly those at higher risk of worsening deformity, functional decline, or pain escalation. Patients with curves >30° at diagnosis are more likely to progress, with greater instability in the coronal and sagittal planes.67 Those experiencing rapid symptom progression despite conservative treatment may require more frequent imaging and clinical assessment.68 Malalignment in the sagittal plane (positive sagittal vertical axis) is strongly associated with worsening disability and should prompt closer follow-up.69 Development of weakness, numbness, or bowel/bladder dysfunction may indicate worsening stenosis or instability, requiring urgent evaluation.70 Patients with low bone mineral density are more prone to curve progression and vertebral collapse, necessitating regular bone health assessments.64 For most patients, serial radiographs should be obtained annually to assess changes in spinal alignment, curve progression, and sagittal balance. In high-risk patients or those with worsening symptoms, imaging every 6 months may be necessary. Advanced imaging (MRI or CT) is indicated when neurological symptoms develop or when there is concern for stenosis, instability, or occult fractures.12 Non-operative management remains a cornerstone in treating ADS, particularly in patients with contraindications to surgery. Tailored exercise programs, pharmacological management, bracing, and multidisciplinary care are essential in optimizing pain control, mobility, and overall well-being. While conservative treatments can effectively manage ADS, appropriate monitoring is critical to identify patients at risk of worsening deformity and functional decline.

Surgical Treatment

Surgical treatments are typically reserved for those who have failed conservative methods or whose condition greatly impacts their quality of life. The decision to pursue surgical treatment is often based on the SRS-Schwab Adult Spinal Deformity classification system or severely symptomatic patients.

The SRS-Schwab system provides healthcare-related quality of life measures based on radiographic parameters and it consists of looking at the curve type and the Sagittal Alignment Modifiers71 The Curve type is based on the coronal deformity location in the spine with a Cobb angle that is >30°.14 It is labeled as N (no major coronal deformity), T (curvature with the apex in the thoracic spine above T10), L (curvature with the apex in the thoracolumbar spine below T10), D (Double major curve in both Thoracic and Lumbar regions).14 The sagittal alignment looks at 3 modifiers: Pelvic Incidence Minus Lumbar Lordosis (PI-LL) mismatch, Sagittal vertical axis, and Pelvic tilt.14 PI-LL is the difference between pelvic incidence and lumbar lordosis. Grades are: O (PIL-LL mismatch < 10°), + (PI-LL mismatch between 10° and 20°), and ++ (PI-LL mismatch >20°). A higher PI-LL mismatch indicates greater sagittal malalignment which can cause increased disability.72 Sagittal Vertical Axis (SVA) is the horizontal distance between the C7 vertebral body plumb line and the posterior superior corner of the sacrum and measures global sagittal alignment. Modifier grades are: 0 (SVA ≤ 4cm), + (SVA between 4 and 9.5cm), and ++ (SVA >9.5cm). The SVA suggests a forward-leaning posture and is associated with compensatory mechanisms and functional limitations.72 Pelvic tilt (PT) is the last modifier and is the angle between the vertical and line connecting the midpoint of the sacral plate to the femoral head axis and it represents the pelvis’s orientation in space. Modifier grades are: 0 (PT ≤ 20°), + (PT between 20° and 30°), and ++ (PT >30°). A higher PT is indicative of pelvic retroversion which is a compensatory mechanism for sagittal imbalance.72

Indications for surgical management are for patients with significant spinal deformity & imbalance such as Cobb angle > 50°, significant sagittal imbalance (SVA >9.5cm, PI-LL mismatch >20°) causing forward-leaning posture and difficulty standing upright, persistent disabling pain refractory to conservative management, neurological deficits, or functional impairment causing reduced quality of life.73 Utilizing the SRS-Schwab modifiers, if the grade is Mild (0) then you will pursue conservative treatment, if the grade is moderate (+) then you trial conservative care and consider surgery if symptoms worsen, and if the grade is severe (++) then there is a high likelihood for requiring surgery.74

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Obtaining a comprehensive history and physical exam assessing the level of pain, functional limitations, neurologic deficits, and medical comorbidities is essential for determining whether to pursue treatment options. Imaging will be necessary to determine Cobb angle and sagittal misalignment which will assist in the need for conservative vs surgical management. If non-surgical management is elected for mild to moderate curvature with minimal to no neurological symptoms, then it will be composed of physical therapy that focuses on core strengthening and postural correction, pain control with NSAIDs and ESI, and activity modification.75 Surgical management as discussed earlier will be reserved for Cobb angle >50°, significant sagittal imbalance, or those who fail conservative management.

New surgical options are available for patients who require it with new advancements in MIS or Halo gravity traction. Post-surgical management will, again, require a multi-modal approach geared towards core strengthening, pain management, and activity modifications.75

Cutting Edge/Emerging and Unique Concepts and Practice

New cutting-edge treatment options are aimed at using the latest advancements in technology to provide the least invasive and conservative treatments possible that will improve patient outcomes. One such new modality is the ScoliSMART activity suit which is a non-invasive device designed to leverage the body’s natural movements to promote spinal alignment and muscle re-education.78 It operates by engaging the body’s natural torque patterns during movement, especially walking, to stimulate the musculature around the spine to promote re-coordination of muscle firing patterns increasing core strength and stability to improve long-term posture.78 Key benefits seen so far are reductions in pain, increased functionality with ADLs, and a reduction in Cobb angle.78

The advancements in surgical techniques in the 21st century have led to a decrease in the amount of anterior spinal surgeries, with anterior/posterior and minimally invasive surgery (MIS) techniques increasing.76 MIS in ASD often involves an anterior retroperitoneal approach with percutaneous posterior instrumentation. The advantages of MIS include minimal blood loss, avoidance of paravertebral muscle dissection, and shorter operative times.79 MIS procedures are indicated in mild to moderate cases of ADS, and when done early in a degenerative course can prevent the progression of scoliosis.79 MIS is limited in severe ADS such that if the deformity cannot be reduced or contain interbody fusions they should be addressed with posterior open surgery.

Advancements in MIS for ASD include robotic-assisted pedicle screw placement, which was found to be safe, effective, more accurate, and with less blood loss than freehand placement.80 Studies also have found that the use of pre-operative halo gravity traction (HGT) in patients with severe cases of adult scoliosis can improve PFTs, reduce Cobb angle, and increase weight gain thus optimizing health before surgeries.77 These and other techniques continue to be explored to improve treatments and outcomes for patients with ADS.

Gaps in the Evidence-Based Knowledge

There are several small cohort studies describing the correlation between bracing and slowing of curve progression in patients with ADS. However, high-quality randomized control studies investigating bracing remain limited.77 Although non-operative treatments are commonly employed, high-quality randomized controlled trials evaluating their efficacy are limited. A systematic review by Schoutens et al. emphasized the scarcity of robust evidence supporting specific non-surgical interventions for ADS, supporting the need for further research in this area.80

Non-operative treatments such as physical therapy, bracing, and injections are commonly utilized, however, randomized controlled trials comparing their efficacy are scarce. The long-term impact of exercise-based interventions on pain relief, functional outcomes, and curve progression remains uncertain.80

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Original Version of the Topic

Aloysia Schwabe, MD, Anand Allam, MD. Scoliosis. 11/14/2011

Previous Revision(s) of the Topic

Andrew I Gitkind, MD, MHA, Nicole Ortiz, MD. Adult Degenerative Scoliosis. 11/8/2021

Author Disclosure

Melissa Mafiah, MD
Nothing to Disclose

Sean Sellwood, MD
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James Borges, MD
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