Differential diagnosis of back pain in adult scoliosis (non operated patients)

Abstract

The relationship between back pain and scoliosis is not clear. Old long-term follow-up studies reported no greater incidence or degree of back pain in adult scoliosis than in normal population when matched for age and sex. At the end of the seventies studies were contradictories. While Fowles et al (1978) concluded that untreated scoliosis could be considered as a disabling disease in the adult particularly after the age of 30, Nachemson (1979) reported a minimal risk of disabling back pain in adult patients with lumbar curves stating that ‘whether severe low back pain occurs more often in adults who have lumbar curves than in those whose spines are straight is open to question’. Later, in 1981, Weinstein et al found that backache was more common in scoliosis patients than in the general population with no relation between back pain and the presence of osteoarthritic changes. Kostuik and Ventivoglio (1981) reported a similar incidence of low back pain (59%) in subjects with lumbar or thoracolumbar curves and normal population. However, they found a correlation between back pain and severity of the curve especially for curves of more than 45°, while patients with no pain tended to have smaller curves. Jackson et al (1983) confirmed that incidence was comparable between adult scoliosis and general population but severity was greater in scoliotic patients. They found that patients with lumbar curve had more pain. Compensatory lumbosacral curves were most painful and disabling. The controversy about how well or bad scoliosis population do it (pain and function) during adult life still continued during the nineties and while the results from the Ste-Justine Adolescent Idiopathic Scoliosis Cohort Study suggested that back pain is responsible for a considerable amount of disability and handicap in later life, the revisited sample from Weinstein et al, showed that untreated late onset idiopathic scoliosis causes little physical impairment other than back pain and cosmetic concerns, with these patients being productive and functional at high level at 50-year follow up. In agreement with the Ste-Justine’s study, Schwab F et al (2003) studied the effect of scoliosis in the self-perception of health and showed that patients in this study averaged scores (SF-36) much lower than the norm from both the general US population in all 8 categories and the US population for ages 55-64 in 7 out of 8 categories of the SF-36 questionnaire. Whether or not idiopathic scoliosis developed during growth will alter health related quality of life later and how conservative and/or surgical treatment will change its natural history is something needing further research, however, from a practical point of view, here the question is not that but how scoliosis condition affects the diagnose, prognosis and management of adult patients suffering from chronic back pain. Adult patients attending our institution - a scoliosisspecific rehabilitation centre - could be divided in two main groups: Group I: Patients attending the clinic with a clear self-conscience of belonging to the scoliosis population because they were mostly diagnosed during childhood or during adolescence – treated or not treated-; Group II: Patients belonging to the back pain population referred to us by their doctors, mostly because they showed a bad response to general rehabilitation and such a bad response was related to a non previously diagnosed scoliosis condition. Generally speaking we could identify patients with idiopathic, congenital and secondary scoliosis in Group I while most of the patients in Group II have developed de novo degenerative scoliosis or scoliosis secondary to any pelvic or lower limbs biomechanical disturbance. The main reasons for consultation in Group I are: documented curve progression, cosmesis, chronic back pain and disability, and prevention in patients that have been followed-up