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Treatment

1. What are the treatment options for adult degenerative scoliosis?
   

   Every patient is unique. No one set of rules fits everybody.
   The usual treatment is conservative (low impact aerobics, non-steroidal anti-inflammatory drugs, pain meds, physical therapy). If it doesn't get better or the patient develops a neurologic problem, the last option is surgery.
   The indications for surgery in adults would be either obvious worsening of the scoliosis as documented on serial x-rays or intractable pain or a progressive neurologic deficit. By far the most common indication for surgery is intractable pain. Before making the assumption that it has recently progressed quickly, we would review the x-rays to document there has been that change.
   There is no reason to make a rapid decision for surgery. The surgery in the adults are tolerated much better now than they used to be due to changes in the techniques, instrumentation and anesthesia. However, it is still a big deal and the risk and morbidity are greater than for adolescents.

   Multiple surgical options are available. They involve straightening the spine with metal implants and fusing the instrumented portion of the spine. These procedures involve all the potential complications of major surgery. The results of the different systems are comparable. Pedicle screws in this country are used primarily in the lumbar spine. Around the world some surgeons are using pedicle screws in the thoracic spine as well. The most important part of the procedure is not the metal implant. If the bone does not heal in a fusion, the implants will eventually fail. Bone graft is usually added to enhance the probability of a fusion. Sources of the bone graft could be from the rib, from the pelvis, from a bone bank or a bone substitute. Rib resection adds to the cosmetic improvement dramatically by reducing the rib hump. With time, the rib grows back, but in a better position.


2. Is there any treatment for chronic pain syndrome?
   

   The treatment is to look for pain generators that could be treated more directly such as spinal stenosis, spine instability, infection, nerve compression, or discogenic pain. Otherwise treatment is directed at how to make life tolerable.
   An assumption is that you have been through the usual list of pain meds - we usually rotate narcotics every few months as the patient develops a tolerance to any one. Our formulary includes propoxyphene, codeine, hydrocodone, talwin, ultram. The anti-depressants are also useful in this way. We avoid oxycodone, demorol, dilaudid and other schedule II drugs. During acute flare-ups of the pain, steroid drugs either orally or epidurally have been helpful. In desperation cases, epidural spinal cord stimulators or intrathecal narcotic pumps have been useful. Consult an anesthesiologist interested in chronic pain management.
   See if the pain generator can be identified and fixed. If the problem is nerve compression or a mechanical instability, a surgical fix is possible. If the problem is arachnoiditis a surgical fix is not practical. Pain management clinics might be an option. With repeat surgeries, your risk of repeat infections is higher than the rest of the population.

3. I have a thoracic disk herniation. What is the treatment regimen for this condition?
   

   Thoracic disc herniations are relatively rare compared to lumbar or cervical disc herniations. Surgical indications are intractable pain or a progressive neurologic deficit that correlates with the anatomical defect seen on imaging studies. Multiple symptomatic thoracic disc herniations are extremely uncommon.
   Non operative treatment is activity modifications, anti-inflammatory meds, pain control and a search for other causes of the pain. For most people, the symptoms of herniated discs will resolve with time. Surgical options vary with the surgeon from discectomy to discectomy and fusion. Our surgical choice is an anterior discectomy and partial corpectomy to decompress the spinal canal. Reconstruction of the anterior column with bone graft and instrumentation is performed to stabilize the involved segment.