Adult Scoliosis

A condition guide by Mr Mohammed Madi, Consultant Orthopaedic & Spinal Surgeon.

Adult scoliosis means a sideways curve of the spine of more than ten degrees, measured on a standing X-ray, in someone whose skeleton has finished growing. That definition sounds the same as scoliosis in a child — but the condition itself is really quite different, and the single most useful thing I can tell any adult with a curve is this: in adults, the number on the X-ray is rarely what matters. What matters is whether the spine is balanced, whether it is pinching nerves or causing pain, and how it affects your life. A modest curve that has tipped the body off balance can be far more disabling than a larger curve that stays beautifully balanced. Throughout this guide I keep returning to how adult scoliosis differs from the childhood and adolescent scoliosis many people have heard of, because understanding that difference explains almost everything about how it is assessed and treated.

This is the most important idea in the whole guide, so I want to put it first. In children and adolescents, scoliosis is overwhelmingly a problem of a growing spine. The classic form, adolescent idiopathic scoliosis, appears in an otherwise healthy young person around the growth spurt, and the central worry is that the curve will get bigger while the child is still growing. Treatment in childhood is therefore aimed at the curve itself — watching it, bracing to try to stop it enlarging during growth, and operating to correct and stabilise it when it becomes severe. The spine is usually flexible, the bone is healthy, pain is often minor or absent, and the concerns are progression, appearance and, in large curves, breathing. In adults the situation is almost inverted. Growth is finished, so the driving force is no longer growth but ageing and wear — degeneration of the discs and joints — together, sometimes, with an old childhood curve that has stiffened and worn with time. The spine is stiffer, the bone may be softer, and the problems that bring adults to see me are pain, trapped nerves and loss of balance rather than a changing appearance. So while a child's curve and an adult's curve may look similar on a film, they are driven by different things, cause different symptoms, and are treated with different goals.

Scoliosis is a curvature of the spine to the side, usually with some rotation of the vertebrae, measuring more than ten degrees on a standing film by a method called the Cobb angle. In adults it takes two broad forms. The first is adult idiopathic scoliosis — essentially a curve that began in adolescence and has carried on into adult life, now with the added effects of decades of wear. The second, and increasingly the commonest, is de novo degenerative scoliosis, which develops for the first time in later adult life out of asymmetric wear of the discs and facet joints, with no childhood curve at all. Population studies show just how common the degenerative form is: in older adults the prevalence of scoliosis rises steeply with age, reported in around a third or more of elderly volunteers in some series. Understanding which type you have matters, because their causes, natural history and treatment differ.

In a child, the Cobb angle — the size of the curve — is the headline number, because it predicts progression and guides bracing and surgery in a growing spine. In an adult, I am far more interested in balance. A well-aligned spine holds the head centred over the pelvis with very little muscular effort, in both the side-to-side (coronal) plane and, even more importantly, the front-to-back (sagittal) plane. When degeneration flattens the natural lumbar curve and pitches the trunk forward, a person has to fight gravity all day with their muscles just to stand upright, which is exhausting and painful. This is why, in adults, we measure spinopelvic parameters — the relationship between the pelvis and the lumbar curve (pelvic incidence and lumbar lordosis), how far the head sits in front of the pelvis (sagittal vertical axis), and how much the pelvis has to tilt back to compensate (pelvic tilt). Large studies have shown that these alignment measures correlate strongly with pain and disability — far better than the Cobb angle does — and that the targets should be adjusted for age, because an older spine neither needs nor tolerates the alignment of a twenty-year-old. In childhood scoliosis these sagittal and spinopelvic measures play a much smaller role; balance-driven disability is largely an adult phenomenon.

There are three practical groups. Adult idiopathic scoliosis is a grown-up version of an adolescent curve; the shape is often familiar and structured, but stiffer than it was, with superimposed disc and joint wear. De novo degenerative scoliosis arises fresh in the lumbar spine in later life from uneven wear; the curves are usually smaller but frequently come with narrowing of the nerve channels, so leg symptoms are common. A third group is secondary scoliosis, where a curve results from another problem such as previous surgery, a fracture, osteoporosis, or a leg-length difference. This is quite unlike the paediatric classification, where curves are grouped as idiopathic, congenital (from vertebrae that formed abnormally before birth), neuromuscular (from conditions such as cerebral palsy or muscular dystrophy), and syndromic — a classification built around cause and growth rather than degeneration.

Here the contrast is stark. Most children and adolescents with idiopathic scoliosis have little or no pain; the curve is usually noticed because of a change in the shape of the back, a prominent shoulder blade or an uneven waistline, and the concern is progression during growth. Adults come to me for the opposite reasons. The commonest complaint is back pain, often muscular and worse towards the end of the day as tired muscles struggle to hold the trunk up. Many also have leg pain, numbness or heaviness — sometimes true sciatica from a pinched nerve, sometimes a cramping tiredness in the legs on walking called neurogenic claudication, caused by narrowing of the spinal canal that so often accompanies degenerative curves. Some describe feeling that they are tipping forwards or to one side, or that they tire very quickly on their feet. Appearance matters to some adults too, but it is usually pain, nerve symptoms and imbalance that dominate.

In a growing child, progression risk is tied to how much growth remains, judged from signs such as the Risser sign and menstrual status, and to the size and pattern of the curve; a large curve in a skeletally immature child can enlarge quickly. Landmark long-term studies of untreated adolescent idiopathic scoliosis followed patients for fifty years and found that, reassuringly, most lived full and functional lives, though larger thoracic curves could progress slowly even in adulthood and back pain was somewhat more common than in people without scoliosis. Adult curves behave differently again. Degenerative curves tend to progress slowly — often a degree or two a year — driven by continuing asymmetric wear, and systematic reviews have tried to identify which curves are most likely to progress, pointing to features such as curve magnitude, rotation and the position of certain vertebrae. The practical message is that adult progression is usually gradual and driven by degeneration, not by growth, so decisions are guided by symptoms and balance far more than by a predicted growth spurt.

Assessment starts with your story and an examination, watching how you stand, walk and balance. The key images are standing, full-length X-rays of the whole spine from the back and the side, because a curve can only be understood in the context of the whole standing skeleton and its balance — something a short film or a lying-down scan cannot show. From these I measure the curve and, crucially, the spinopelvic and sagittal parameters that tell me about balance. Where there are nerve symptoms, an MRI scan shows the discs, the spinal canal and the nerve channels. This is a more balance- and nerve-focused work-up than in a child, where the emphasis is on curve pattern, flexibility and remaining growth.

Most adults with scoliosis are managed without surgery, and I always begin here unless there is a pressing reason not to. The mainstays are staying active, physiotherapy and core conditioning to help the muscles support the spine, sensible pain management, and attention to bone health, weight and general fitness. Where a specific nerve is inflamed, a targeted injection can calm symptoms and help confirm the source of leg pain. It is worth being clear about bracing, because this is another real difference from childhood. In a growing child, a brace can genuinely reduce the chance of a curve worsening during growth — this was shown convincingly in a major randomised trial. In an adult, a brace does not correct or reliably halt a curve; at most it is sometimes used for short-term comfort. So bracing is a childhood tool, not an adult corrective treatment. Good non-operative care meaningfully helps many adults, though studies also show that those with marked imbalance and severe symptoms are less likely to be satisfied with non-operative treatment alone.

I consider surgery when symptoms are severe and persistent despite good non-operative care, when nerves are significantly compressed, or when the spine is badly out of balance and tipping forward or sideways. The goals of adult surgery are again quite different from childhood. In a child, the aim is to correct the deformity and stop it progressing in a growing spine, while preserving as much growth and motion as possible — hence growth-friendly strategies in very young children, such as growing rods, that allow the chest and spine to keep developing. In an adult, the aims are to take pressure off the nerves, to restore balanced alignment so the trunk sits centred over the pelvis again, and to relieve pain — accepting that this usually means fusing part of the spine. Depending on the problem, this can range from a limited decompression and short fusion for a degenerative curve with a trapped nerve, up to a longer realignment with instrumentation and, where the spine is stiff, controlled bone cuts called osteotomies to rebuild the sagittal profile. Restoring good, age-appropriate alignment is central, because the alignment achieved strongly predicts how well a person does.

I believe in being straight about this. Surgery for adult scoliosis and adult spinal deformity can be transformative, and prospective multicentre studies show meaningful, lasting gains in pain and quality of life for well-selected patients — indeed the disability of severe adult deformity has been shown to rival that of conditions such as arthritis, heart and lung disease. But it is major surgery with a genuine complication rate that is higher than in fit adolescents. Recognised issues include the junction above a long fusion breaking down over time (proximal junctional kyphosis), the fusion failing to knit (pseudarthrosis), and a real chance of needing further surgery, alongside the general risks of large operations, which rise with age and other health problems. This is why patient selection, medical optimisation and careful surgical planning matter so much, and why the decision is always individualised and shared. By contrast, correction of adolescent idiopathic scoliosis in an otherwise healthy young person is generally a more predictable operation with a lower complication rate — another reflection of the fundamental difference between operating on a young, healthy, flexible spine and reconstructing an older, stiffer, worn one.

To draw the threads together: childhood and adolescent scoliosis is a disease of the growing spine, where the curve size and its progression during growth are the main concern, the spine is usually flexible and pain-free, bracing can help during growth, and surgery aims to correct and stabilise the deformity while respecting growth and motion. Adult scoliosis is a disease of the ageing spine, where balance, pain and nerve compression matter far more than the Cobb angle, degeneration rather than growth drives progression, bracing is not corrective, and surgery aims to decompress nerves and rebuild balanced, age-appropriate alignment — a bigger undertaking with higher risks but real rewards in the right person. Holding this distinction in mind is the key to understanding why your scoliosis, as an adult, is assessed and treated the way it is.

This guide is intended for general education and is not a substitute for personalised medical advice. Every spine and every person is different, and the right approach depends on your individual diagnosis, symptoms, balance, bone health, general health and personal circumstances. Any decisions about investigation or treatment should be made together with your treating spinal surgeon or healthcare professional.

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This information is for general patient education and is not a substitute for an individual consultation. Always seek personalised advice from a qualified spinal specialist.