Adult spinal deformity treatment
While treatment goals of Adult spinal deformity include reduction of pain, symptomatic neural compression, and disability due to deformity, the methodology and biomechanics of ADS treatment differ greatly from treating Juvenile idiopathic scoliosis.
Deformity correction focuses on restoration of global alignment, especially in the sagittal plane, and decompression of the neural elements. General realignment goals have been established, including sagittal vertical axis <50 mm, pelvic tilt <22°, and lumbopelvic mismatch <±9°; however, these should be tailored to the patient. Operative management, in carefully selected patients, yields satisfactory outcomes that appear to be superior to nonoperative strategies. ASD is characterized by malalignment in the sagittal and/or coronal plane and, in adults, presents with pain and disability. Nonoperative management is recommended for patients with mild, nonprogressive symptoms; however, evidence of its efficacy is limited. Surgery aims to restore global spinal alignment, decompress neural elements, and achieve fusion with minimal complications. The surgical approach should balance the desired correction with the increased risk of more aggressive maneuvers. In well-selected patients, surgery yields excellent outcomes 1).
Options
Quantification of severity of spinal deformity and classification helps guide appropiate treatment paradigms 2) 3).
The options are based on clinical symptoms (axial back pain ± radiculopathy vs. radiculopathy alone) and degree of abnormalities in sagittal balance.
1.- Observation.
2.- Focal decompression.
3.- Surgical correction of deformity
MIS
Hybrid MIS + open
Traditional open surgery (TLIF, PLIF….).
Neuropathy most often originate from foraminal compromised on the concavity of the curve, but can be seen on the convexity in the setting of facet joint hypertrophy and may improve with indirect decompression and correction in the coronal plane. Significant central stenosis (neurogenic claudication) may require concomitant direct decompression in addition of deformity correction.
Sagittal balance correlates with quality of life measures.
Recent evidence has revealed sagittal plane malalignment to be a key driver of pain and disability in this population and has led to a significant shift toward a more evidence-based management paradigm.
Nonoperative management is recommended for patients with mild, nonprogressive symptoms; however, evidence of its efficacy is limited. Surgery aims to restore global spinal alignment, decompress neural elements, and achieve fusion with minimal complications. The surgical approach should balance the desired correction with the increased risk of more aggressive maneuvers. In well-selected patients, surgery yields excellent outcomes 4).
Not every adult with a spinal deformity requires treatment. In fact, the vast majority of adults with deformity do not have disabling symptoms and can be managed with simple measures such as periodic observation, over the counter pain relievers and exercise. The exercises are aimed at strengthening the core muscles of the abdomen and back and improving flexibility. Some patients may benefit from short term use of braces to get pain relief. Braces do not have any long term effect on the degree of the deformity. For persistent leg pain and other symptoms due to arthritis and pinched nerves, injections such as epidurals, nerve blocks or facet injections may provide temporary relief. These are usually performed by a pain management physician who may also prescribe stronger medications. Unfortunately, stronger pain medications can also be habit forming and have to be used with caution.
Nonoperative treatment
The success of nonoperative treatment was more frequent among younger patients and those with less severe deformity and frailty at BL, with BL frailty being the most important determinant factor 5).