The treatment of adult scoliosis is very individualized and based on how symptomatic a patient is, degree of curve, where the curve is located on the spine, how quickly the curve is progressing, existence of other medical conditions, and age/overall health of the patient.
Surgery may be recommended when conservative treatments such as physical therapy and interventional pain procedures are not effective in controlling symptoms, the degree of scoliosis has shown significant progression on x-rays, or when the scoliosis has caused serious neurologic deficits. The goal of surgery for scoliosis is to correct the curve to the limits of what is safe, halt its progression, and decompress any affected nerves or regions of the spinal cord. Successful surgical treatment meeting those three goals usually gives patients their life back with resultant pain reduction and alleviation of neurologic symptoms.
Since spinal deformities vary from patient to patient, no two surgical treatments will be the same, and the medical team will choose specific surgical procedures for the patient depending on the details of the diagnosis. Surgical techniques for scoliosis have come a long way recently with the development of minimal access, minimally invasive techniques, although traditional open surgery may sometimes be necessary. The neurosurgeons and orthopedic surgeons at Och Spine at New York-Presbyterian/Weill Cornell Medical Center, New York- Presbyterian Brooklyn Methodist, and Och Spine at New York- Presbyterian Queens have been trained in the most advanced reconstructive surgical techniques and can determine the best treatment for each patient and each situation.
It is critical to be evaluated by a surgeon who has extensive experience in the treatment of scoliosis. There are three options for treatment of patient with scoliosis: decompression only, short-segment fusion, or long-segment fusion. When seeing an experienced surgeon, the surgeon first evaluates whether a patient with scoliosis can be adequately treated with a decompression-only procedure. If not, then the question is whether the patient’s symptoms can be resolved with a short-segment fusion. Only when the first two treatment plans not appropriate to the specific patient is a long-segment fusion performed. (The surgeon must also decide whether to approach from the front, side, or back; see ALIF, LLIF, and TLIF for Scoliosis).
Decompression-only surgery: There are situations when taking pressure off the spine without repairing the scoliosis is enough in alleviating a patient’s symptoms. This pressure is usually caused by a disk herniation or overgrown ligaments/bone. In these situations, surgery is usually performed as an outpatient procedure or with just a short stay at the hospital without the need to place any cages, rods, or screws. These operations include foraminotomies, laminectomies, laminotomies, and microdiscectomies. Surgeons would then follow the patient over time, with periodic X-rays to ensure that the scoliosis curve does not progress. The benefit of this approach is that it does not require any hardware in the spine (thus maintaining normal flexibility of the spine) and allows for the shortest recovery before getting back to normal activities. These operations in the appropriate patients can be performed with minimally invasive or ultra-minimally invasive endoscopic techniques, which further minimize recovery times and complications even further.
Short-segment fusion: “Fusion surgery” includes several different procedures that typically involve placing metallic cages, rods, and screws into the spine to straighten out a scoliotic curve. The benefit of a fusion operation is that it straightens out scoliosis and restores adequate alignment of the spine. The downside is that every set of bones that are attached with hardware will then not move at all with respect to one another. This decreases the range of motion of the spine, which might be problematic to a patient, especially if more than a few levels of the spine are fused together. For that reason, if a decompression-only surgery is not appropriate for a certain patient, the goal of an experienced scoliosis surgeon is to determine the smallest number of levels of the spine that need to be fused and still give adequate relief of symptoms. The benefit of fusing the smallest number of vertebral segments is that it allows the patient to maintain some mobility and flexibility of the spine. Once the decision is made that a short-segment fusion is the best option for the patient, an experienced scoliosis surgeon will determine whether a minimally invasive option is indicated for the patient. Minimally invasive lumbar fusions do not require the large incision or the muscle retraction typically used in conventional fusions. Patients undergoing this procedure usually have faster recovery times that those having open surgery. These minimally invasive surgeries include surgeries from the back of the spine (TLIF), front of the spine (ALIF), or side of the spine (LLIF). A recent advance is the use of a computerized image guidance system for many patients undergoing lumbar fusion. This has the advantage of aiding the surgeon in optimal placement of screws and avoiding injury to delicate nerve tissue.
Long-segment fusion: There are times when the only option for a patient is for the surgeon to place metallic hardware across the entire region of scoliosis. The benefit of this approach is that the degree of the curve is much better corrected than with a short-segment fusion. The negative of performing a long-segment fusion is that patients will be left with stiff, immobile spines. Most patients are tolerant of this back stiffness as most of daily activities require much more mobility from the hips than they do of the spine. Regardless, every individual’s deformity is different and requires a tailored approach. The goal of any reconstruction is to restore alignment and decompress neural elements. Some patients may fare better with a posterior approach (surgery approached from the back). Some may best be treated with a two-stage approach, with anterior (from the front) and posterior surgery. Lastly, some patients may be best treated with a three-stage approach with anterior, lateral (from the side), and posterior portions to the procedure. Most patients requiring long-segment fusions will require osteotomies or cuts in the bone to increase flexibility of the spine prior to correction of the scoliosis.
Reviewed by: Osama Kashlan, MD, MPH
Last reviewed/last updated: November 2024
Illustration by Thom Graves, CMI
