For patients who cannot stay functional despite a concerted effort at nonsurgical treatments, surgery may be considered.
Most patients will not need surgery to correct the scoliosis itself, because it is unlikely the curve will progress enough to cause deformity or disrupt lung and heart function (as it can in some cases of idiopathic scoliosis). Instead, the goal of surgery for degenerative scoliosis is not to prevent deformity, but rather to focus on the following two goals:
- To reduce the patient's level of pain, and;
- To help the patient maintain his or her ability to function in everyday activities.
Lumbar Decompression plus Fusion Surgery
Patients who experience severe leg pain when walking (also called lumbar stenosis and neurogenic claudication) are often candidates for surgery. Typically, spinal decompression surgery is recommended for patients with lumbar stenosis. However, when there is curvature involved, this surgery alone can result in further instability and a progression of the curvature, so a spinal fusion procedure is done in conjunction with the decompression.
As with idiopathic scoliosis surgery, this surgery involves fusing the involved portion of the spine to stop the motion at the affected joints. The fusion process uses a series of rods, hooks and screws as a temporary splint to hold the spine in a straight position. Bone (either the patient's own or cadaver bone) is then added to the back of the spine to begin the fusion process, which continues to heal over the next several months. (See also Scoliosis Surgery)
It can take anywhere from 3 to 12 months for pain to improve after surgery, so only the patients with the most severe symptoms and marked activity limitations should consider surgery.
The one time in which surgery may be considered sooner rather than later is if the curve has demonstrated a progressive tendency over a period of time and the patient is still relatively young (such as 55 to 65 years old). Performing the surgery while the patient is younger has advantages because the patient is better able to tolerate the procedure. However, this is still a tough call and a decision to proceed with surgery should only be made after careful consideration.
Potential Risks and Complications
Adult degenerative scoliosis surgery is more difficult than adolescent scoliosis surgery for several reasons.
- Patients are older and tend to have other medical issues, which leads to an increased chance of a peri-operative medical complication
- Often, because the patients are older, osteoporosis is also present. This makes gaining purchase (fusion) in the bone with spinal instrumentation systems a difficult process
- Fusing the lumbar spine at multiple levels often requires a surgical approach from both the front and back to get a solid fusion, which makes it a more extensive surgery.
- The fusion may need to be carried down to the sacrum, and getting a solid fusion to heal in this area can be difficult.
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Because of these factors, surgery is an extensive procedure with potential for significant blood loss and associated risks, and it is not at all uncommon for the patient to require blood transfusions postoperatively. The procedure usually takes the better part of a day to complete (6 to 12 hours). Sometimes the surgery is staged, with the anterior fusion (in front of the spine) done first, then days or weeks later the posterior portion (in the back of the spine) is done.
Other risks include:
- Excessive blood loss
- The rods breaking or the hooks dislodging (especially if the patient is osteoporotic)
- Cerebrospinal fluid leak
- Failure of the spine to fuse
- Continued postoperative pain
- Neurological injury
As with most types of surgery for back pain, the biggest risk is that despite undergoing a large spinal fusion surgery, the patient may still have debilitating pain after the surgery. Success rates of significantly improving the patient's level of pain with this type of surgery are usually only about 60% to 70%.