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The Spine Journal 7 (2007) 428–436

Review Article

Degenerative lumbar scoliosis associated with spinal stenosis
Avraam Ploumis, MD*, Ensor E. Transfledt, MD, Francis Denis, MD
Twin Cities Spine Center, 913E 26th Street, Minneapolis, MN 55404 USA
Received 16 March 2006; accepted 29 July 2006

Abstract BACKGROUND CONTEXT: Degenerative de novo scoliosis is commonly present in older adult
patients with spinal pain. The degenerative process including disc bulging, facet arthritis, and lig-
amentum flavum hypertrophy contributes to the appearance of symptoms of spinal stenosis in these
patients.
PURPOSE: The etiology, prevalence, biomechanics, classification, symptomatology, and treat-
ment of degenerative lumbar scoliosis in association with spinal stenosis are reviewed.
STUDY DESIGN: Review study.
METHODS: Retrospective analysis of studies focused on all parameters concerning degenerative
scoliosis associated with stenosis.
RESULTS: There is a variety of treatment methods of degenerative scoliosis based on symptom-
atology and radiologic measurements of scoliosis and stenosis. Satisfactory clinical results reported
in relevant retrospective studies after operative treatment range from 83% to 96% but with increased
percentage of complications. An algorithm for operative treatment corresponding to a newly pro-
posed classification system of degenerative lumbar scoliosis with associated canal stenosis is
presented.
CONCLUSIONS: There is an increasing prevalence of degenerative scoliosis in the aged popula-
tion. Even though the exact percentage of patients with symptomatology of spinal stenosis is not
known, the main goal is to provide pain relief and improved functional lifestyle with minimum
intervention. Ó 2007 Elsevier Inc. All rights reserved.
Keywords: Degenerative scoliosis; Spinal stenosis; Decompression; Fusion

Introduction consisting of axial rotation on the vertical axis, lateral
translation toward the convexity of the curve, and anterior
Adult scoliosis is defined any curvature of the spine
translation in the sagittal axis. Trammell et al. [4] originally
more than 10 in a skeletally mature individual. The term
described rotatory olisthesis as the apparent lateral sublux-
degenerative de novo scoliosis (DDS) refers to scoliotic
ation of one vertebral body upon another seen in the ante-
curves developing after skeletal maturity without previous
roposterior films. Other terms used in the past for the same
history of scoliosis. Scoliosis occurs de novo in later life pathology are lateral spondylolisthesis, translatory shift,
and is associated not only with severe back or leg pain
lateral olisthesis, and lateral subluxation. It occurs most fre-
but also with complicated surgical outcomes [1].
quently at the L3–L4 level, in women, and increases with
Degenerative spondylolisthesis is very common in cases
age and magnitude of the curve.
of degenerative scoliosis. In a study of patients with degen-
Lumbar spinal stenosis is a common problem in the older
erative scoliosis, 55% of them had additional degenerative
adult population. It is defined as a pathologic condition
spondylolisthesis [2]. Rotatory olisthesis coexists in 13% to
in which the neural elements are compressed by bone, soft
34% of adult scoliosis cases [3,4]. It is a triaxial deformity
tissue, or both resulting in ischemia of nerve roots [5]. It is
distinguished in central stenosis, when there is abnormal
FDA device/drug status: not applicable. narrowing of the spinal canal, and lateral stenosis, when
Nothing of value received from a commercial entity related to this there is lateral recess (subarticular stenosis) or foraminal
manuscript.
* Corresponding author. Twin Cities Spine Center, 913 E 26th Street,
(foraminal stenosis) narrowing [6]. Symptoms of neuro-
Minneapolis, MN 55404. Tel.: (612) 775-6200; fax: (612) 775-6222. genic claudication and radiculopathy predominate. Fre-
E-mail address: ploumis@med.auth.gr (A. Ploumis) quently, it is accompanied by degenerative olisthesis and
1529-9430/07/$ – see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.spinee.2006.07.015

A. Ploumis et al. / The Spine Journal 7 (2007) 428–436 429

degenerative scoliosis. The adjuvant scoliosis complicates facet joints lack the second most significant factor of inter-
neural compression and makes surgical treatment more dif- vertebral stability in the horizontal anteroposterior Z and
ficult [7]. longitudinal vertical Y axis of the global reference system.
Aging affects bony structures, discs, ligaments, facet Therefore, the vertebra above in the spinal unit progress
joints, and muscles. This causes wedging of both vertebral gradually to forward olisthesis and rotation that leads to
bodies and discs and may ultimately lead to a domino-like rotatory scoliosis and stenotic symptoms caused by the
effect of rotation and translation into the upper lumbar and kinking of the neural elements by the malrotated pedicles
sometimes thoracolumbar spine. Degenerative scoliosis, [13–15].
reduced lumbar lordosis, and neural element compression
is the final end result. Also, the combination of ligamentum
flavum hypertrophy, facet hypertrophy, disc collapse, and Prevalence and natural history
olisthesis cause neural compression.
The prevalence of degenerative scoliosis is reported to
The purpose of this article is the in-depth analysis of
be from 6% to 68% [8,11,16,17] and increases with age
degenerative scoliosis associated with symptoms of canal
[2]. Pritchett and Bortel [2] studied 200 patients more than
stenosis. A comprehensive and simple classification system
50 years old (70% women) with late-onset scoliosis. They
with corresponding algorithm for operative treatment for
found that most of the lumbar degenerative curves did not
degenerative lumbar scoliosis associated with spinal steno-
exceed 60 and progressed an average 3 per year. Factors
sis is presented.
for curve progression were Nash- Moe grade 3 apical rota-
tion, a Cobb angle more than 30 , lateral vertebral transla-
tion of 6 mm or more, and the prominence of the L5
Etiology vertebra in relation to the intercrest line. On the contrary,
Murata et al. [12] showed in the early phase of degenerative
Decreased bone density was initially considered to be
curves they might also regress after consequential wedging
the cause of degenerative scoliosis [8,9], but this has
in the disc space or the vertebral bodies for compensating
changed after finding that no significant difference exists
imbalance.
in the bone density between patients with degenerative sco-
The mean age of patients with degenerative scoliosis
liosis and patients with adolescent scoliosis of the adult
was less than 60 years in 38% of Perennnu’s study and
[10]. Actually, degenerative changes, especially of the disc,
33% in Kostuik’s study, whereas 41% of scoliotic patients
vertebral body wedging, and facet joint arthrosis are
were younger than 64 years old in Robin’s study. In Tram-
responsible for the appearance of ‘‘de novo’’ scoliosis and
mell’s study, the average age of patients with rotatory sco-
degenerative rotatory scoliosis [11,12].
liosis was 41 years. Right-sided degenerative scolioses
A cadaver study of 19 lumbar spines with degenerative
worsen with aging twice as much than left-sided scoliosis
olisthesis without scoliosis showed it was mostly associated
[3,17]. This is associated also with deterioration of rotary
to disc degeneration and osteophytosis of apophyseal joints
olisthesis.
and less to fractured endplates. The joint capsules become
There are no studies estimating what percentage of pa-
attenuated as a new false articular surface is created on the
tients with degenerative scoliosis will need evaluation and
lamina next to the inferior articular process. In the same
treatment for their symptoms, axial back pain, or symptom-
study, canal constriction was not found because of olisthe-
atology of spinal stenosis. It is also unknown what is the
sis, but this was without acknowledging the possible steno-
natural history of these symptoms without treatment. How-
sis of soft tissues (ligamentum flavum, facet capsules, and
ever, the symptoms of spinal stenosis irrespective of scoli-
so on) [13].
osis have been found to be improving over time in 15% of
Kobayashi et al. [11] studied the prevalence of degener-
cases, deteriorating during the initial 2 to 3 yeas of follow-
ative de novo scoliosis in normal-aged people and con-
up requiring surgical intervention in 40% of the patients
cluded that more than 5 mm lateral osteophyte of an
and maintaining their status over long-term in the rest
endplate or more than 3 asymmetric tilt of a disc space
45% of the cases [6,18].
are risk factors for development of degenerative scoliosis.
This confirms the notion that degenerative scoliosis starts
as disc degeneration [11,12]. Biomechanics
In addition, aging may induce ‘‘degenerative myopathy’’
leading to rupture of the equilibrium and kyphotic deforma- It is known that the kinematics and the coupling pattern
tion of the spine. Repetitive torsional loads may progres- are different from one spinal region to another. The cou-
sively provoke rotational deformation of the posterior pling pattern of lateral bending and axial rotation is con-
vertebral elements and lead to degenerative rotatory scolio- verging in the lumbosacral junction meaning that right
sis [14]. lateral bending coincides with right axial rotation of L5
Iatrogenic instability caused by iatrogenic facetectomies vertebra on the sacrum. However, in the lumbar spine, the
is another cause of rotary olisthesis. The vertebrae without coupling pattern of lateral flexion and axial rotation is

430 A. Ploumis et al. / The Spine Journal 7 (2007) 428–436

diverging; that means right axial rotation results in left lat- pain and degenerative rotatory olisthesis especially at L3–
eral bending [19,20]. L4 and L4–L5 levels. However, the mean age of patients
In scoliosis, thoracic spine motion is balanced but the was 62 years in Perennou’s study and 23 years in Tram-
coupling mechanism is abnormal. Instead of axial rotation mel’s study.
to be toward the concavity, it is occurs into the convexity Velis and Thorne [30] and Kostuik et al. [31] described
of the curve [21]. It is unknown what the etiology is of this lateral olisthesis as an important prognostic factor for the
abnormal coupling motion pattern. development of back pain and curve deterioration after
On the contrary, Veldhuizen and Scholten [15] found skeletal maturity. Scwab et al. [32] comparing radiographic
that the coupling mechanism of axial rotation and lateral parameters with VAS scores in adult scoliotic patients
bending does not differ in normal and scoliotic spines. found that pain correlates with L3 and/or L4 obliquity, lat-
However, they supported that there exists a special coupling eral rotatory olisthesis, lumbar lordosis, and thoracolumbar
mechanism between sagittal plane motion and axial rota- kyphosis. Curve magnitude and number of levels involved
tion in the scoliotic spine. in the curvature were unrelated to pain. Degenerative insta-
Disc and facet degeneration leads to increased axial bility is the cause of pain and a common pathway in the
rotation of the functional spinal unit. The increase in axial progression of all types of adult scolioses.
rotation caused by spinal degeneration was more pro- The etiology of the pain might be mechanical or neuro-
nounced than the increase of motion in flexion-extension genic [33]. Commonly, mechanical back pain presents in
[20]. Degenerative scoliosis is also followed by decreased cases with longstanding idiopathic scoliosis. It appears with
lumbar lordosis and, subsequently, low back pain [2,12]. muscle pain because of fatigue of spinal muscles (along the
There have been described various methods for determi- whole length of the spine and specifically in the convex
nation of vertebral rotation [22–24]. The most widely used side of the curve) and is attributed to the loss of lumbar lor-
method of radiographic determination of vertebral rotation dosis. The pain in the concavity of the scoliosis is caused
is the pedicle method (grade 0–IV) introduced by Nash and by facet arthritis and degenerative changes of the disc
Moe [22]. Grade 0 defines the neutral vertebra when there spaces (disc changes, ligament tension and tears, spurs,
is no asymmetry between the anteroposterior pedicle pro- and so on).
jection in the convex and the concave side. Grade IV is The sagittal gravity line passes in front of the S1 verte-
the total disappearance of the pedicle in the concave side, bral body and back musculature is over functioning for
whereas the pedicle on the convex side migrates past keeping an upright position. The notion that clinical symp-
midline. toms of back pain increase linearly with the degree of
positive sagittal imbalance is supported by the findings of
Glassman et al. [34] in a retrospective review of 752
Clinical presentation
patients with adult scoliosis.
The incidence of low back pain in patients with degener- Neurogenic pain is mainly a feature of patients with de
ative scoliosis is not significantly more common than in the novo scoliosis. It is possible, although, to be present in
general population. Paraspinal muscle electrodiagnostic ex- cases of adult idiopathic scoliosis. Neurogenic pain is
amination has helped to define the association between radio- caused by either foraminal nerve root or dorsal root gaglion
logical spinal stenosis and back pain [25]. Lumbar scoliosis compression (concave side of the curve) or central spinal
with degenerative changes most prominent at the scoliotic stenosis leading to neurogenic claudication.
apex can produce lumbar stenosis resulting in disabling It is imperative to distinguish the neurogenic claudica-
low back pain and leg pain in a neurogenic claudication mode tion symptoms from the pain caused from vascular claudi-
[26]. However, sometimes leg symptoms appear from the cation. The pain in neurgenic claudication is reduced if the
contralateral side because of the lumbosacral curve [27,28]. patient acquires a forward flexed (like bicycling) or sitting
Liu et al. [29], in their study of patients with degenerative position. The pain in vascular claudication is relieved by
lumbar scoliosis and stenosis, concluded that L3 and L4 standing still and accompanied with peripheral vascular
nerve roots are compressed in the foramen or extraforami- loss and skin changes.
nally on the concave side of the main curve, whereas the The accompanying medical comorbidities in these el-
L5 and S1 roots are affected more by lateral recess stenosis derly patients should not be overlooked. It should be kept
at the convex of the lumbosacral fractional curve. in mind that the patient is being operated on is a whole per-
However, rotatory olisthesis does correlate with back son, not just a spine. Keeping the surgical intervention as
pain associated with idiopathic scoliosis. It is significantly minimal as possible should be the ideal goal.
associated with increasing age and magnitude of the curve
[4]. Smaller Cobb angles and lateral and rotatory olisthesis
Lumbar spinal stenosis
are more frequently seen in degenerative scoliosis than in
adult idiopathic scoliosis. Spinal stenosis is the narrowing of the spinal canal and can
On the contrary, Perennou et al. [3] showed that there is be local, segmental, or generalized. It is divided into the con-
definitely correlation between anterior femoral radicular strictive stenosis caused by bony or ligamentous reduction in


the size of the canal and the restrictive stenosis, which is at- nerve roots because of vertebral rotation and subluxation.
tributed to intracanal fibrosis (i.e., arachnoiditis) restricting Additionally, hypertrophy of ligamentum flavum, disc
the mobility of neural elements [35]. Usually, it is acquired degeneration and protrusion, facet joint osteophytosis, and
as in degenerative diseases or spondylolisthesis and less com- cysts of the facet joints are significantly decreasing the
monly is congenital. The degenerative disease of the spine functional capacity of the spinal canal.
leads to constrictive-compressive type stenosis. It reduces
substantially the spinal reserve capacity; this is the ratio Classification
between the horizontal distance of posterior middle of the
lamina from the posterior end of the vertebral body and the The only classification system that exists for degenera-
anteroposterior diameter of neural canal measured in CT tive lumbar scoliosis addresses only the existence of rota-
transverse sections. Spinal reserve capacity is actually a function or/and lumbar lordosis loss. It does not include
tional factor of spinal canal and is better than other static rotatory olisthesis or stenosis. Simmons characterized as
measurements like the AP canal diameter [35]. It is com- type I the degenerative scoliosis with no or minimal rota-
monly admitted that absolute stenosis exist when AP canal tion, whereas type II was defined as the degenerative scoli-
diameter is less than 11 mm [36]. However, the use of subjec- osis with rotational deformity and reduced lumbar lordosis
tive criteria to characterize spinal stenosis by radiologists and [1,43,44].
relevant clinical physicians (spine surgeons, neurologists, Schwab et al. [32] recently published a classification of
and physiatrists) led to high variability of results for the same adult scoliosis based on radiographic measurements in
patients [37]. Radiologists specialized in spine imaging sub- anteroposterior and lateral standing radiographs. They
jectively grade the stenosis as mild, moderate, and severe, measured the lordosis L1–S1 and the obliquity of L3 verte-
according to the degree. bral body and divided the population in three types of
The criteria for central and lateral stenosis are difficult to severity with decreasing lordosis and increasing L3
define. Verbiest [38] was the first to introduce the terms of obliquity [32].
absolute and relative value of spinal stenosis. The shape of There is need for a classification system that it will ad-
the spinal canal, the facet joints, and the measured spinal dress the segmental type of deformity, the sagittal spinal
dimensions (interpedicular distance, sagittal diameter of contour, and the symptomatology. The proposed classifica-
the dural sac, and pedicle length) are some of the measure- tion system is shown in the Table 1. However, the validity
ments evaluating spinal stenosis [39]. Hypertrophy of the and reliability of this system are still under investigation,
ascending facet is the main cause of lateral stenosis [7]. and this is a best-guess approach based on our experience.
Biomechanical studies of the foramen of the lumbar spine
proved that during flexion and contralateral lateral bending Radiographic evaluation
of the spine the foraminal cross sectional area increases,
whereas in extension or ipsilateral lateral bending the Plain full-spine standing AP and lateral radiographs are
foraminal area decreases. Distraction may increase the fo- necessary to evaluate case of degenerative scoliosis associ-
raminal height, but the osteophytic changes continue to ap- ated with rotary olisthesis. In the coronal plane, useful pa-
ply pressure to the nerves in the stenotic foramen [40]. In rameters are the following: 1) C7PL (plumbline from the
histologic studies of the neural foramen, it was found that center of C7 vertebral body) horizontal distance from
the nerve root and ganglion are within the upper pole of CSVL (central sacral line), 2) scoliosis Cobb angle (major,
the foramen above the disc and never occupy more than hemicurve, and proximal thoracic), 3) proximal stable and
35% of the cross-sectional area. In foraminal morphometric distal stable vertebra of the major curve, 4) L3 endplate
studies of cadaveric spines, it was found that the foramen obliquity, 5) L4 endplate obliquity, 6) maximal lateral olis-
have variable size between 40 and 160 mm2 and defined thesis (mm), and 7) maximal vertebral rotation (Nash-Moe
the normal limits of foraminal cross-sectional area in the grades).
sagittal plane [41]. Measurement of vertebral foramina In the sagittal plane, parameters to be measured are the
using calipers is superior to that with CT scan [42]. following: 1) sagittal Cobb angle (thoracic [T1–T12], thor-
Often, the radiological findings are more severe than the acolumbar [T10–L2],and lumbar [T12–S1], 2) PLC7-S
patients’ symptoms. Studies of patients with lumbar spinal
stenosis have shown that there is no statistically significant
Table 1
correlation between the intensity of pain and the degree of
stenosis. Most commonly, the radiologic image of stenosis Type I: minimal or no rotation
Type II: rotatory olisthesis (intersegmental rotation and translation)
was more extensive than expected from the clinical picture
Type III: rotatory olisthesis and structural coronal (O4cm distance from C7
[39]. Therefore, spinal stenosis can be either radiographic- plumbline) or positive sagittal imbalance (O2cm from anterior sacral
only spinal stenosis or symptomatic spinal stenosis with corner)
a combination of clinical and radiographic characteristics. A: back pain without radicular sx
It is mentioned earlier in the etiology of rotatory scolio- B: sciatic pain (from the lumbosacral hemicurve) 6back pain
C: femoral pain (from the major curve) 6back pain
sis that there is compression of the dura and traction of the


horizontal distance of the C7 plumb line starting in the cen- Nonoperative treatment
ter of C7 body and the anterosuperior corner of S1, 3) max-
Requirement for surgical treatment of degenerative sco-
imal anteroposterior olisthesis (mm), and 4) sagittal pelvic
liosis is the application and failure of nonoperative treat-
tilt index [32].
ment. The first step of pain management is the use of
The most predictive radiologic parameters for the asso-
nonsteroidal antiinflammatory drugs and nonnarcotic anal-
ciate clinical presentation of the patients with adult scolio-
gesics as well as the avoidance strenuous spinal motions. A
sis are the upper endplate obliquities L3 and L4, lateral
session of oral administration of methylprednizolone is pre-
olisthesis, lumbar lordosis, and thoracolumbar kyphosis
scribed in cases of acute onset severe pain. Tricyclic antide-
[32]. The positive sagittal balance has been shown to corre-
late statistically significantly with the clinical presentation, pressants (amitriptylin) and anticonvulsion (carbapentin)
drugs are preserved for cases of chronic pain. In case of
preoperatively and postoperatively [34].
symptoms persistence, the use of custom-made spine im-
In order to assess the degree of spinal stenosis it is im-
mobilization and vertebral joints’ injections follow. Epidu-
perative to review a CT scan or MRI of the lumbar spine.
ral steroid injections may provide short- or long-term relief
Especially the T2 sequense of the MRI shows the size of
of symptoms. They are performed mainly for radiculopathy
the spinal canal and the existence or intrathecal fluid in
but also for back pain with radiographic spinal stenosis.
the transverse sections, whereas the patency of the foramen
Translaminar injections should be done always under fluo-
is better shown in the sagittal views. The myelography is
not used so often nowadays because of its side effects; how- roscopy in order to avoid missing the target. Transforaminal
epidural injections are indicated for one-level stenosis with
ever, the CT myelogram gives a profound demonstration of
unilateral symptoms and are certainly more selective to the
those levels with spinal stenosis (Figs. 1–3).
location of spinal stenosis than translaminar injections. The

Fig. 1. (A) Anteroposterior and (B) lateral view full spine of a patient with degenerative rotary scoliosis with the apex to the left. Note the lateral olisthesis at
L2–L3 and L3–L4 and the positive sagittal imbalance.


the 3-year follow-up [46]. Furthermore, the systematic side
effects (gastrointestinal, circulatory, haematological, and re-
nal) from the prolonged use of nonsteroidal anti-inflamma-
tory drugs should be kept in mind and their prescription be
limited only for short-term use.

Operative treatment
All nonoperative ways of treatment should be exhausted
before considering surgical treatment. The aim of the sur-
gery is to decompress the comprised neural elements, in
case of symptomatic spinal stenosis and to end with a bal-
anced and stable spine in the coronal and sagittal plane,
when there is imbalance. However, these patients are el-
derly patients with other comorbidities, and surgical treat-
ment should be performed in a safe and effective way.
The ideal is to proceed with only the least aggressive pro-
cedure, usually posterior only, that would involve both
decompression and stabilization, if needed, of the spine.
The most frequent indication of surgical treatment is
pain [31,48,49]. However, the degree of any individual pa-
tient is very objective and cannot be measured indepen-
dently. Usually, the most important question that a patient
has to answer is how much his/her symptoms affect his/
her life. The patients who present with back pain only
should be warned that they would not be completely pain
free, especially after a fusion surgery.
Progressive neurologic deficit is another indication for
surgery. Increasing leg weakness and paresthesias that are
not caused by vascular pathology should make the surgeon
to suspect spinal stenosis. Symptoms originating from spinal
stenosis typically appear between the 5th and 7th decade of
life (40–60 years) [50]. Blood loss should be controlled to
minimum amounts. Finally, bone quality should be exam-
ined before undertaking a surgical procedure, especially in
aged patients, in case of instrumented fusion.
Patients who present with symptoms of spinal stenosis
and have degenerative scoliosis less than 20 and without
Fig. 2. Computed tomography myelogram transverse cuts at the (A) L3– instability could be treated with spinal decompression only
L4 and (B) L4–L5 level showing the central and subarticular stenosis. [51]. Especially, male patients with large vertebral struc-
tures and stabilizing osteophytes can tolerate more than
time delay between epidural injections should be at least 3 2-level laminectomy without fusion [52].
weeks, and the total number of injections allowed is no more Otherwise, patients with degenerative scoliosis more
than three to four within 6- to 12-month interval. In a recent than 15 to 20 , lateral subluxation, or dynamic instability
randomized prospective study to assess the efficacy of epidu- should be treated with decompression and fusion. Simmons
ral steroids injections versus intramuscular steroid and anes- selects different fusion strategies according to his classifica-
thetic for patients with lumbar stenosis, it was found that even tion’s types of degenerative scoliosis. For type I, he prefers
though there was a significant reduction of pain in the short- the short instrumented fusions with distraction forces ap-
term the long term results did not show any difference in the plied to the concavity of the curve in order to decompress
number of patients that needed surgery [45]. Abdominal and the nerve roots. For type II, he prefers the long instrumen-
back muscle strengthening together with swimming are tation and fusion with a derotation maneuver for scoliosis
considered other methods of pain management [1,8,46,47]. reduction. In situ rod contouring into lordosis and proper
The efficacy of nonoperative treatment (analgesics, exer- patient bed positioning are methods for restoring better me-
cises, and steroid injections) was studied in 49 patients with chanical alignment and lordosis. A less extensive fusion
radiographic and clinical spinal stenosis. Thirty-three (67%) surgery can be preferable even though the upper and lower
patients showed mild or significant clinical improvement at end of the fusion are not parallel to the sacrum [53,54].


Fig. 3. (A) Anteroposterior and (B) lateral view full spine after anterior interbody fusion L1–L4, posterior decompression L3–L5, and posterior instrumented
fusion T9–S2.

Pedicle screws are considered the most appropriate fixation with 44 months average follow-up treated with decompres-
method for the aged osteoporotic bone with absent posterior sion and fusion. Eighty-three percent of the patients reported
elements after decompression [55]. In case of significant severe pain before surgery, and 93% reported mild or no pain
decompensation in the sagittal and coronal plane, it is often postoperatively. Scoliosis was reduced from 37 to 18 at the
imperative to extend the fusion to the sacrum. Additional fix- latest follow-up. Shapiro et al. [56] reported 94% satisfaction
ation points in the sacrum and the pelvis reduce the increased rate at 2 years postoperatively in 16 patients treated with an-
strains to the implants and help the healing of the fusion. terior and posterior surgical reconstruction for adult idio-
In Table 2, an algorithm of treatment of patients with de- pathic scoliosis and stenosis. The Oswestry Disability Index
generative scoliosis and stenosis is presented based on the improved from 44.3 and preoperatively to 26.4 at the most re-
classification system presented in Table 1. An extensive cent follow-up, and the curve correction reached 50.4%.
study of our patients treated using the aforementioned algo- Hansraj et al. [51] in a study involving 47 patients with com-
rithm is under publication and showed statistically signifi- plex lumbar stenosis only (without scoliosis) and decompres-
cantly improved outcomes (measured by SF-36, Oswestry, sion surgery reported 89% to 98% satisfaction rates in
and VAS scores) postoperatively. different functional outcomes (ability to walk, pain, muscle
strength and balance) with 92% to 94% chance of not needing
revision surgery average 39 months postoperatively.
Results of surgical treatment
Frazier et al. [57] reported 15 patients with scoliosis and
The degree of pain relief after adult scoliosis surgery is stenosis treated with lumbar decompression only. All the
debatable. There are not many studies assessing the results patients had postoperatively increased VAS score compared
of surgical treatment for adult patients with scoliosis and with preoperatively, even though the improvement of the
stenosis. Simmons and Simmons [43] studied 40 patients scoliotic curve did not correlate with the outcomes.


Table 2 In the literature, there is a controversy in the question if
comorbidities increase the risk for postoperative complica-
Type I Type II Type III tions [60,61]. Elderly patients could safely have spine sur-
gery with an outcome similar to younger patients, if we
deemed that they do not have increased comorbidities [61].
The most important complications that can happen are
NO Grade 1 (5mm) Grade 2 (6-10mm) or 3 CORONAL OR serious blood loss, blindness, cerebral infraction, myocar-
LATERAL LATERAL (11mm) LATERAL SAGITTAL
ROTATORY ROTATORY ROTATORY IMBALANCE
dial infarction, paralysis, neurological deficit, infection-
OLISTHESIS OLISTHESIS OLISTHESIS sepsis, failure or breakage of the implants, pseudoarthrosis,
pneumonia, deep vein thrombosis, and death [59]. A special
STABLE SEGMENT UNSTABLE report should be performed regarding lumbar lordosis loss
2mm motion in SEGMENT
dynamic x-rays 2mm motion in or flat-back syndrome [63]. It is caused by distraction of
dynamic x-rays the lower lumbar spine during fusion or translational ky-
phosis of thoracolumbar spine cranially to the upper end
DECOMPRESSION IATROGENIC
INSTABILITY of fusion. It leads to sagittal plane imbalance of the spine,
YES LONG
chronic low back pain, and inability of keeping erect pos-
NO
SELECTIVE FUSION OF THE FUSION TO ture. Possible iatrogenic aetiology of flat back syndrome
NON FUSION MAJOR CURVE OR THE TL AREA +
UNSTABLE SEGMENTS + DECOMPRESSION should be avoided during thoracolumbar scoliosis surgery.
DECOMPRESSION

Conclusions
The procedure can involve posterior only or combined Degenerative scoliosis is appearing more frequently be-
anterior and posterior approach. Marchesi and Aebi [55] cause of increased life duration or iatrogenic instability.
treated 27 patients with an average age of 60 and curves Nonoperative treatment should be exhausted before pro-
from 22 to 82 with decompression and posterior segmen- ceeding with surgical treatment, especially in cases needing
tal instrumented fusion. In 4.5 years of average follow-up, major reconstructive procedures. The optimal is to manage
86% of the patients were satisfied with pain relief and in- the whole pathology with only one operation. Lumbar de-
creased walking ability. The average curve correction was compression, fusion, and instrumentation are appropriate
50%, and lumbar lordosis increased from 45 to 54 [55]. for most of the patients with degenerative lumbar scoliosis
Grubb et al. [58] reported 40% pseudoarthrosis rate in pa- and stenosis. The main goal is to provide pain relief and
tients with degenerative scoliosis treated with posterior-on- improved functional lifestyle with minimum intervention.
ly fusions to the sacrum, whereas all the cases treated with
anteroposterior approach fused uneventfully. A comprehen- References
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