1、Degenerative Scoliosis Wang Xuepeng M.D.Hangzhou First Peoples Hospital Epidemiology?can be differentiated into two major groups,i.e.,primary degenerative scoliosis or de novo scoliosis and secondary degeneration of adult idiopathic scoliosis?the prevalence of scoliosis in patients older than 50 yea
2、rs is about 6%,the average age of those seeking medical care is in the sixties.?there is a potential for curve progression with an average of 3.3 one year Pathogenesis?the asymmetric degeneration of the disc and the facet joint leads to an asymmetric loading of the spinal segment and consequently an
3、 asymmetric deformity,i.e.,scoliosis or kyphosis?the formation of osteophytes at the facet joint(spondylarthritis)and at the vertebral endplates(spondylosis)contributes to the increasing narrowing of the spinal canal together with the hypertrophy and calcification of the ligamentum flavumand joint c
4、apsules,creating central and recessal spinal stenosis Classification?the classification of Lenkes may be able to cover the adult idiopathic scoliosis group with secondary degeneration but is not necessarily adequate for the primary degenerative scoliosis type Classification?Schwab distinguished thre
5、e groups based on measurements of the endplate obliquity of L3 in the frontal plane,and of the lumbar lordosis measured between the L1 and S1 superior endplates in the sagittal plane Classification Cardinal Symptoms Back Pain?is the most frequent clinical problem of adult scoliosis?patients often co
6、mplain of axial back pain due to segmental instability?at the site of the curve can be localized either at the apex or in its concavity?unbalanced,overloaded and stressed paravertebral back muscles may become very sore and in return will not contribute to balance,consequently becoming part of a vici
7、ous circle Spinal Claudication?is the second most important symptom of adult degenerative scoliosis and may express itself as:radicular claudication central claudication?the roots are compressed not necessarily on the concave side due to a narrow foramen,but often on the convex side Neurological Com
8、promise?neurological deficits occur late?is the third most important clinical presentation and may include individual roots,several roots or the whole cauda equina with apparent bladder and rectal sphincter problems Increasing Deformity?osteoporosis accelerates curve progression?larger curves tend t
9、o progress faster than small curves for biomechanical reasons Physical Findings Standard Radiographs?full body standing radiographs are indispensable?radiographs sometimes exhibit clues to the etiology of the curve(primary vs.secondary)?important to look at earlier radiographs to understand the natu
10、ral history and therefore the etiology of the curve Magnetic Resonance Imaging?is the imaging modality of choice to explore neural compromise and disc degeneration Computed Tomography?computed tomography with or without a myelogram is the diagnostic imaging?method of choice in the case of diagnostic
11、 uncertainties related to the three dimensional Interventional Radiological Procedure?in the context of the evaluation of the pain source,spinal injection studies are especially helpful since their findings may change the therapeutic approach Additional Diagnostic Tools?temporary immobilization cast
12、 in the form of a thoracolumbar orthosis(TLO)or thoracolumbosacral orthosis(TLSO)to see whether an overall stabilization and fusion of the whole scoliotic spinal area could be beneficial?neurophysiologic studies may be helpful to identify the responsible level?osteodensitometry(DEXA)is indicated whe
13、never there is a suspicion of osteoporosis because of the implications with regard to curve progression and potential spinal fixation Non-operative Treatment?The non-surgical treatment options basically consist of:non-steroid anti-inflammatory drugs(NSAIDs)muscular relaxation pain medication muscle
14、exercises gentle traction(in selected cases)spinal injection studies orthosis Non-operative Treatment?manipulations and physical activation should be avoided because they may increase the pain?therapeutic epidural and selective nerve root blocks as well as facet joint blocksmay help to control the p
15、ain temporarily.?a well-fitted brace to support the painful spine area may be necessary Operative Treatment Correction Procedures?whether or not a degenerative scoliosis should be corrected remains a crucial and complex question.?the treatment of a degenerative scoliosis has different goals than the
16、 treatment of adolescent scoliosis.It depends on several factors:Correction Procedures?Sagittal balance is most important Surgical Techniques?debate continues on the indications for a lumbosacral fusion?in young patients with secondary degenerative scoliosis,it is better to omit L5/S1 from fusion wh
17、enever possible in order to prevent iliosacral joint degeneration or an early hip problem.It is also usually preferable to stop at L4 in a lumbar curve whenever possible?However,a fusion to the L5 vertebra is necessary when the condition of the L4/5 facet joint is poor Surgical Techniques Take Home Messages Thank You！
