The National Scoliosis Foundation is receiving an increasing number of inquiries about a condition known as degenerative scoliosis. To find out more about this type of curvature, I was asked to interview Dr. Howard A. King, a Clinical Associate Professor of Orthopaedic Surgery at the University of Washington. Dr. King is internationally recognized for his research and published works in the field of scoliosis. His practice is affiliated with both Children's Hospital and Medical Center and Swedish Hospital in Seattle.

Q: Dr. King, many of our readers are wondering about degenerative scoliosis. Why are we hearing more about it now?
A: As a category, degenerative scoliosis has probably been around for the past 10-15 years. I think we're seeing more of it now for several reasons: 1) people are living longer; 2) they're healthier and more active and putting more demands on their spine; 3) they're more likely to say, "Hey, this bothers me," whereas in the past, they tended to accept the condition as an inevitable part of aging.

Q: Would you define degenerative scoliosis, and tell us who is affected by it?
A: When we talk about degenerative scoliosis, we're referring to two types of individuals. First, there is the adult who has pre-existing scoliosis. That person's spine starts to show signs of wear and tear or osteoarthritis - which happens to all of us as we age - but because of the deformity, their spine starts to collapse and their curve can progress. The other type of person has no scoliosis to start with, but as he or she ages, the spine starts to show signs of wear and tear and it collapses asymmetrically. These individuals actually develop scoliosis later in life, even though they didn't have a pre-existing condition.

Q: Are you saying that osteoarthritis -- the wear and tear condition you mentioned -- is the cause of degenerative scoliosis?
A: Osteoarthritis certainly can cause degenerative scoliosis, but so can osteoporosis, the condition that is accompanied by brittle and/or porous bones and is associated with loss of calcium from bones. Some of our patients have only one of these problems; many suffer from both. (For more information about osteoporosis see the Medical Update on pain in the Spring/Summer 1991 issue of THE SPINAL CONNECTION or write to the Foundation for a copy of that Medical Update).

Q: What are some other characteristics of patients with degenerative scoliosis who come to you for help?
A: We're seeing patients in their late fifties and sixties. Earlier in their lives, they had curves generally above 40 degrees. Some of their curves stabilized for awhile, whereas others' curves progressed slowly over time. The patients I've been seeing have tended to have curves in the lumbar [lower spine] or thoracolumbar [mid-spine] area.

Q: What are some of the symptoms that are characteristic of degenerative scoliosis?
A: Many patients say they have back pain; the pain can occur generally along the area of their curve, either on the concavity or the convexity. Sometimes the pain occurs at the bottom of the spine; this is because the area above it has worn out, causing the lower portion to become overloaded and stressed with additional weight. Some patients notice they're a bit shorter than they used to be. Some claim that their waistline or posture is different than it was, say, five years ago. Often times patients will complain that their clothes don't seem to fit properly anymore. Recently a number of patients have complained that their rib cage seems to be sitting on their pelvis; these folks have deteriorating lumbar curves which are causing them to shrink and lose their waistlines. Although this condition doesn't interfere with their internal organs, it makes patients uncomfortable.

Q: What kinds of treatments are available for patients with degenerative scoliosis?
A: Depending on the severity of the condition, we might recommend any of the following: 1) physical therapy and the use of non-steroidal anti-inflammatory drugs (NSAIDs); 2) bracing; 3) surgery.

Q: Before getting into the specifics of treatment, first tell us how you go about evaluating a patient.
A: When people come to us for the first time, we want to know, Why are they here? Are they shorter? Having pain? Are their clothes not fitting as well? Are they having neurological symptoms such as numbness or weakness in the leg(s)? If they have a thoracic [upper spine] curve, are they starting to develop shortness of breath or do they fatigue easily or has their endurance decreased? Perhaps most important we want to know, Are they really changed? We talk with them extensively and try to obtain old x-rays or chart notes that might give us clues. Of course, we also want to get a general overview of the patient's health. We need to know, is the patient basically healthy, or does he or she have a significant medical problem - such as a malignancy of the spine, for example-that might be causing some of the above symptoms?

Q: Let's say the patient's symptom is strictly backache. What would you prescribe?
A: If the patient's symptom is strictly backache and there's no history of curve progression, we would probably start them with physical therapy and NSAIDs such as asprin or ibuprofen. Then we would get them involved in some type of aerobic conditioning program (general fitness exercises such as walk-ing and swimming). Maintaining a good level of aerobic fitness is really important for anybody with any kind of spinal problem. Recent scientific data suggests that if you are aerobically fit, you will have less trouble with your spine. More over, your endurance will be better, your proper weight will be maintained, and your endorphin levels - known as nature's pain killers - will be higher. Typically, patients get involved in activities such as swimming, stationary bicycle riding, or using a cross country ski machine. We're finding that aerobic exercises really help patients with mild cases of degenerative scoliosis. Those with curves under 40 degrees can be involved with pretty active programs; those between 40 and 60, we would consider on a case-by-case basis.

Q: Will any of these exercises stop a curve from progressing?
A: Exercise will not change the curve; it will do absolutely nothing to change the scoliosis. What we're trying to do is to condition the person so that he or she can better accommodate the scoliosis. Exercise won't solve the problem, but it may help manage a symptom such as pain.

Q: When a person's age and/or physical condition is such that aerobic conditioning is not recommended, what do you prescribe instead?
A: In some cases we would recommend the use of a rigid brace or TLSO - thoracolumbar sacral orthotic. As many of your readers probably already know, this type brace is known as an underarm brace - it's made of polypropylene and is therefore thin, lightweight, and quite unobstrusive. We recommend the TLSO for a short period of time to support the back and take pressure off the weight bearing joints of the spine. This gives patients some relief so that they can eventually get their conditioning and exercise program up to speed. The brace is a short term measure; however, our goal is to get the patient's back muscles working again via exercise and physical conditioning.

Q: Can the brace stop a curve from progressing?
A: In adults, no - it's strictly for symptomatic treatment.

Q: In your opinion, who might be a candidate for surgery?
A: The characteristics of the surgical candidate might include the following: 1) someone who has clearly documented evidence of curve progression; 2) an individual whose thoracic curvature is causing pulmonary functions to deteriorate; 3) a person whose lumbar curvature is causing neurological problems such as weakness in the leg(s); 4) a patient whose symptoms interfere with his or her lifestyle.

Q: Once the scoliosis specialist and the patient have agreed to go ahead with the surgery, what surgical techniques might be employed to correct degenerative scoliosis?
A: There are many techniques used today. For example, to treat large or lumbar curves, my colleagues and I are combining posterior with anterior surgeries - in other words, we'll do one surgery to remove discs and add bone graft in the front (anterior) of the spine, and then go to the back (posterior) of the spine and use instrumentaaon (rods) and/or wiring techniques. Some of the techniques include Cotrel-Dubousset and Luque-Galveston. [For descriptions of these or other surgical techniques sug- gested, consult an orthopedic spinal specialist.) When possible, we do both these surgeries on the same day instead of a week or two apart. Same-day surgery gives the patient just one recovery period, which reduces various psychological and physical stresses.

Q: Do most patients wear a post-surgical brace?
A: Almost always I recommend that adult surgical patients wear a light-weight brace. Because their bones are softer and thier curves more rigid than younger individuals, we have to do more extensive surgeries, and the brace protects them and adds an element of safety. Most patients wear the brace full time for six to nine months. Of course, they can remove it for showers or baths.

Q: What can you tell us about the risks involved with these surgical techniques?
A: Because this is major surgery where we may employ a number of approaches and because we're dealing with a group of people who are older, we find that complication rates are higher, though the complications typically are minor. Generally speaking, the surgical techniques we use today can be performed pretty safely.

Q: Is there anything the older surgical patient can do to reduce the possible risk of complications?
A: We have found that age is not as important as the person's health. I recommend patients strive for good nutrition, work toward and maintain their ideal weight, and stay as fit as they possibly can. Obviously, a careful pre-op medical examination is also critical to one's surgical success.

Q: Many of our adult readers have scoliotic curves but have never experienced any symptoms of degenerative scoliosis. What are the chances that these individuals will develop the problem in the future?
A: We simply don't know the answer to that question. Most of the 30 to 40 degree adult curves we see are benign, but there are some individuals whose curves continue to creep on. In general, would say the person with a 30-degree curve will be just fine in the future, and I'd recommend that he or she (and everyone else for that matter) stay fit, exercise, and eat properly. Those individuals with 40-degree curves should be checked periodially (every 5 years or so) and be measured for height on a regular basis. And those folks in the 40 to 50-degree range should be watched pretty carefully by a scoliosis specialist; if their curves progress significantly, they should be treated surgically.

Q: What do you foresee regarding degenerative scoliosis?
A: We're probably going to see more patients -as discussed, people are living longer, they're healthier, more active, and more ikely to come in and say "this is interfering with my life." I also believe we're going to see surgical techniques improve. We'll inderstand more about the natural history of degenerative scoliosis because we'll be spending more time studying it. We'll learn more about preventing and treating osteoarthritis and osteoporosis. I'm hopeful that in time, we'll have a better idea of which people are at risk so that we can take care of their problems when they're younger.