Transcription:
Treatment Options for Adults with Spinal Deformities

Melanie Cole (Host): You may think that scoliosis is a condition that affects children, but many adults need help dealing with scoliosis and other spinal deformities. My guest is Dr. Justin Smith. He's a neurosurgeon and co-director of the UVA Spine Center. Welcome to the show, Dr. Smith. What are the most common spinal deformities in adults? We've heard about children wearing those back braces when they're young to keep their spines set while they grow, but what about adults?

Dr. Justin Smith (Guest): Thank you for having me. In older adults, the most common spinal deformities result from the spine wearing out, and they're referred to as degenerative conditions or degenerative scoliosis. It's actually fairly prevalent in older adults. In younger adults, it's often leftover deformity from childhood or adolescence that either didn't need to be treated and has progressed somewhat or perhaps just was not treated sufficiently. So, in younger adults, it's often leftover deformity from childhood; in older adults, it's often accumulated changes of wear and tear that result in the deformities.

Melanie: Now, people are back pain, leg pain, pain going through your buttocks. Back pain is so common. So how do you know that it's an actual deformity versus some sort of a stenosis or really muscular pain, anything?

Dr. Smith: Right. That's a great question. Often, people don't know that they have a deformity until they come in and have an x-ray done and the x-ray shows that there is a curvature to the spine. In younger children, the curves are often very pronounced and obvious from the outside, but in older adults, the curves can be much less dramatic, and maybe only apparent on x-rays. And so, really, the way we diagnose it is based on plain x-rays in the office.

Melanie: Okay. So you've done your plane x-rays. Is this something that had they seen it earlier, would they have seen it as a child? Would they have seen it as a teenager or in their twenties and been able to maybe do something in advance to that?

Dr. Smith: That's a great question as well. In older adults, there's often nothing that can really be done other than just trying to stay fit and taking care of yourself and not smoking and some of the risk factors for the spine wearing out. But there really isn't a way of preventing it. Certainly, in children, there are ways, sometimes, with braces and surgical treatment to try to treat it so that it doesn't become as much of a problem in adulthood. But the most common form is as the spine wears out, there really isn't, unfortunately, a lot to do at this point to prevent that.

Melanie: What about treatments? If this is something that you find out that you have, is it painful just like an arthritic condition? Is it more painful? What are you doing about it?

Dr. Smith: In older adults, the prevalence of this kind of a condition is very high. There are some studies that suggest that once we reach our sixties and seventies, about half of us will have some curvature to the spine. So obviously, there are a lot of patients out there, people out there who don't have symptoms from it, and if they don't have any symptoms or concerns, we don't do anything about it other than perhaps following it over time, when patients present -- they're often presenting with back pain, as you mentioned, or leg pain because nerves may get pinched from the deformity or narrowing or stenosis as we call it. In those kinds of situations, we often try to really pursue non-operative treatments first, such as physical therapy, medications, sometimes steroid injections, and we try to help patients with the symptoms. Certainly, if they present with neuro deficits, such as weakness or evidence of spinal cord compression or something eminent, then we may talk about surgeries sooner than later. But otherwise, we try to avoid surgery if we can. In patients who don't respond to those non-operative treatments, surgery can become an option, preferably large surgeries, typically though so we try to avoid them if we can.

Melanie: Since this occurs in many older adults, surgery then becomes a little bit even more something controversial. You're not sure you want to do it. It's a big deal for older people. Now, if we're talking about physical therapy, stretching, strengthening exercises and you mentioned medications. Do anti-inflammatories, things for -- is it pain management? What are you doing medication-wise?

Dr. Smith: For the medications, anti-inflammatories are often very helpful, such as the nonsteroidals. Of course, we have to be careful with kidney function and other issues as well, but the nonsteroidals can often be very helpful. Other medications such as Neurontin to help sometimes with some of the nerve pain. Narcotics, we typically try to avoid if we can, because they tend to not, because long-term solutions, for most cases. But that's typically as far as medications go, and we often will send people to a pain management specialist if it gets to that point where we want to try some of the more atypical medications.

Melanie: Now, I know that you mentioned narcotics, so this is something I know you want to steer clear of. In pain management, is that what they're doing? What are they doing for that pain?

Dr. Smith: Different pain management specialists have different philosophies. I generally would encourage patients to avoid narcotics if they can. Sometimes, they're very older adults who are not good surgical candidates, but nothing else seems to be helping and pain specialists will try a limited dose of narcotics. Sometimes, that's enough to help them get through the day. But by in large, a long-term solution with narcotics is often not the best, because it's really kind of masking the symptoms and patients can build tolerance to the narcotics. That's often not the best solution.

Melanie: Now, is there a time when spine stabilization surgery is required?

Dr. Smith: Required is a word...

Melanie: Okay, not required. It might be called for or might be something that the patient...

Dr. Smith: Considered, right. Sometimes, it can be more or less required if there's spinal cord compression or progressive neurological deficits, which isn't as common. But in those kinds of cases where you could consider acquired. But otherwise, it's a very personal decision. It really comes down to quality of life and how much the deformity and the pain is impacting the patient. If it gets to a point where the non-operative therapies are just not providing satisfactory quality of life and relief of the symptoms and the pain, then surgical options are often discussed with the patient.

Melanie: Is it worthwhile to keep fit, to keep stretching, strengthening, keep the muscles around your spine strong? And please, what about back braces?

Dr. Smith: Absolutely. It is certainly important to keep strong. I often -- when I initially see patients in the clinic, we'll send them for, of course, a physical therapy and some basic conditioning. If they can't tolerate land-based, sometimes, we'll do aqua therapy, so physical therapy in the water. I think it's very important to stay fit and to keep the muscles around the spine strong. As far as back braces in adults, they really have not been shown to be of benefit. My concern with those is that they can lead to some deconditioning of the muscles. In children while they're still growing and the deformity is rapidly progressing because their bones are still growing, braces can be helpful to hold the spine in place as it's growing. But in adults, I generally try to steer clear of braces.

Melanie: That's good advice. Is there something people can do for their own lifestyle pain management at home? Icing your back, any of those kinds of things, do they work?

Dr. Smith: I think it's very individualized, and I often tell patients that -- they'll ask if heat or ice is better, and I'll say, "Try each and see what works better." It's really a personalized situation. Some patients may find that laying in certain positions or stretching in certain ways are helpful, and I think, really, the key is just finding what helps for the individual.

Melanie: Certainly, it is. It's very personal. Now, can you sort of wrap it up in the last minute or and a half or so, Dr. Smith, about adult spinal deformities, adult scoliosis? Give the patients a little bit of information how you work at UVA.

Dr. Smith: At UVA, I see quite a few initial patients each day, and I often just get to know them first and talk about what their condition is and go through their imaging studies and discuss their symptoms and try to come with a plan. Again, as I mentioned, I try to avoid surgery when we can. Certainly, when it comes to the point, if they need surgery, we're a center that does a lot of adult deformity surgery, and we're a center where patients should consider coming because you want a specialist for these kinds of big surgeries. But that said, we're not a center that really pushes surgery. We're a center that tends to focus on non-operative therapies first, and when those fail, then we can talk about surgical options. The goal is really just to try to individualize the therapy and help to improve the quality of life of each individual patient.

Melanie: Thank you so much, Dr. Justin Smith, neurosurgeon and co-director of the UVA Spine Center. For more information, you can go to uvahealth.com. You're listening to UVA Health System Radio. I'm Melanie Cole. Thanks for listening. Have a great day.